,vt 


UNIVERSITY  OF  CALIFORNIA 
HALIFORNIA  COLLEGE  OF  MEDICINE 

MAR  1  5  1973 
IRVINE,  CAUFORNIA  92664 


SURGERY  OF   THE 


Prostate,  Pancreas,  Diaphragm, 

Spleen,  Thyroid,  and 

Hydrocephalus. 


A    HISTORICAL    REVIEW. 


BY 

BENJAMIN  MERRILL  RICKETTS,  Ph.B.,  M.D., 

CINCINNATI. 


CINCINNATI 
1904 


zm^  \oo 


INTRODUCTION. 


1^^ 


In  dealing  with  the  surgery  of  the  subjects  herein  mentioned,  all  available 
literature  has  been  examined,  chronologically  arranged  and  placed  in  chapters. 

So  far  as  possible  all  of  the  conditions  which  are  surgical,  or  may  become  so, 
have  been  considered  in  each. 

An  attempt  has,  therefore,  been  made  to  place  the  literature  especially  in  the 
hands  of  surgeons  and  writers.  It  may  be  of  equal  value  to  students  and  practi- 
tioners as  well. 

It  is  to  be  regretted  that  the  hospital  work  bearing  upon  these  subjects  has 
not  reached  the  current  medical  literature,  for  it,  no  doubt,  contains  many  valu- 
able reports  that  would  greatly  aid  in  solving  many  of  the  problems  which  can- 
not otherwise  be  solved. 

Hospital  work  alone  is  not  responsible  for  this  loss  of  valuable  material. 

There  are  many  cases  met  with  by  the  general  practitioner  in  the  rural  dis- 
tricts, and  cities  as  well,  which  are  never  heard  from. 

It  is  the  multitude  of  cases  from  which  the  most  valuable  deductions  are  made. 

Many  of  the  references  have  been  transcribed  several  times  by  pen  and-  type 
after  having  left  the  hands  of  the  author,  thus  giving  opportunity  for  error  in 
duplication  and  otherwise.  An  effort  has  been  made  to  correct  these  so  far  as 
possible;   however,  many  remain  as  found. 

In  many  instances  a  given  case  is  reported  by  several  authors.  Such  refer- 
ences have  been  preserved  because  of  their  value,  in  that  one  might  be  available 
while  another  would  not  be  so. 

Benjamin  Merrill  Ricketts,  Pii.B.,  M.D. 

N.  W.  Cor.  Fourth  and  Broadway,  May  20,  1904. 


M 


Surgery  of  the  Prostate. 


CHAPTER. 

I.  Anatomy 
II.  Etiology 

III.  Cystotomy 

IV.  Massage 
V.  Injection 

VI.  Ligation  of  Cord 
VII.  Ligation  of  Iliac  Arteries 
V''.I.  Vasectomy 
\X.  Castration 
X.  Prostatotomy 
XI.  Galvano-Cautery 
XII.  Perineal  Prostatotomy 

XIII.  Suprapubic  Prostatectomy 

XIV.  Combined  Perineal  and  Suprapubic 
XV.  Abscess 

XVI.  Tuberculosis   . 
XVII.  Hydatid  Cysts 
XVIII.  Prostatic  Calculi 
XIX.  Carcinoma 
XX.  Sarcoma 
XXI.  Cancer 

XXII.  General  Surgical  Bibliography 
XXIII.  Miscellaneous 


Prostatotomy 


PAGE. 

I 
I 

4 

5 
5 
S 
5 
5 
6 
8 
8 

9 

II 

13 
14 
15 
16 
16 
17 
17 
18 
18 
31 


Surgery  of  the  Pancreas. 


CHAPTE 

R. 

I. 

Anatomy 

II. 

Abnormalities 

III. 

Physiology 

IV. 

Experimental 

V. 

Pathology 

VI. 

Fat  Necrosis 

VII. 

Lymphoma 

VIII. 

Lipoma 

IX. 

Lumbricoides 

X. 

Fungosities 

XI. 

Calculi 

XII. 

Cysts    . 

XIII. 

Hemorrhage 

XIV. 

Abscess 

XV. 

Syphilis 

XVI. 

Tuberculosis 

XVII. 

Gangrene 

XVIII. 

Carcinoma 

XIX. 

Sarcoma 

XX. 

Cancer 

XXI. 

Hernia 

XXII. 

Surgery 

XXIII. 

Miscellaneous 

Bibliography 


45 
46 

47 
50 
51 
53 
S3 
.«i3 
54 
54 
54 
55 
57 
58 
59 
59 
60 
60 
62 
63 
65 
65 
69 


Surgery  of  the  Diaphragm. 


CHAPTER. 

PAGE. 

I.  Anatomy            .             .             .             .             .             .             •             .75 

II.  Anomalies 

.  77 

III.  Surgery 

.  78 

IV.  Rupture 

.  79 

V.  Injuries  and  Lacerations 

.  8o 

VI.  Hernia  . 

.  8i 

VII.  Congenital  Hernia 

.    82 

VIII.  Abscess 

■  85 

IX.  Gangrene 

.  86 

X.   Lipoma 

.  86 

XI.  Ossification 

.  86 

XII.  Angiomata 

.  86 

XIII.  Echinococcus    . 

.  86 

XIV.  Tuberculosis     . 

•  87 

XV.  Carcinoma 

.  87 

XVI.  Sarcoma 

> 

•  87 

XVII.  Miscellaneous  Bibliography 

.  87 

vii 


Surgery  of  the  Spleen. 


CHAPTER. 

I. 

Anatomy 

. 

II. 

Abnormalities 

III. 

Displacements 

IV. 

Experimental 

V. 

Injuries 

VI. 

Tuberculosis 

VII. 

Gangrene 

VIII. 

Syphilis 

IX. 

Ossification    . 

X. 

Anthrax 

XI. 

Abscess 

XII. 

Hydatid  Cysts 

XIII. 

Hemorrhage 

XIV. 

MiscellaneoKs  Cysts 

XV. 

Carcinoma      . 

XVI. 

Sarcoma 

XVII. 

Unclassified  . 

XVIII. 

Tumor 

XIX. 

Enlargement 

XX. 

Pathology 

XXI. 

Splenotomy   . 

XXII. 

Splenectomy 

XXIII. 

Splenopexy    . 

XXIV. 

Splenorrhaphy 

XXV. 

General  Surgery 

XXVI. 

Miscellaneous  Biblic 

)graph_ 

f 

92 

95 
96 

97 
99 
102 
103 
103 
103 
104 

105 
107 
108 
109 
109 
109 
no 
no 
112 

"3 
119 
119 
120 
121 
121 
130 


Surgery  of  the  Thyroid. 


CHAPTER. 

PAGE. 

I.   Anatomy     .          .              .              .              .              •              •              -139 

II.   Physiology 

142 

III.  Anomalies  . 

144 

IV.   General  Goitre    . 

H5 

V.  Etiology 

146 

VI.  Endemic 

149 

VII.  Thyroiditis 

150 

VIII.  Tumor      .... 

153 

IX.  Simple  Goitre     . 

154 

X.  Spasm 

154 

XI.  Paralysis 

154 

XII.  Displacement 

154 

XIII.  Congenital 

154 

XIV.   Domesticated  Animals 

154 

XV.  Exopthalmic  Goitre 

154 

XVI.  Cretinism 

178 

XVII.  Concretions 

178 

XVIII.  Cystic  Goitre      . 

• 

179 

XIX.  Echinococcus 

182 

XX.  Blood  Cysts 

182 

XXI.  Abscess    . 

183 

XXII.  Gangrene 

184 

XXIII.  Tuberculosis 

184 

XXIV.  Syphilis    . 

184 

XXV.  Cancer      . 

18s 

XXVI.  Carcinoma 

186 

XXVII.   Primary  Carcinoma 

.87 

XXVIII.  Cylindrical  Epithelioma 

187 

XXIX.  Medullary  Carcinoma    . 

187 

XXX.  Sarcoma  . 

187 

XXXI.  Cysto-Sarcoma  . 

188 

XXXII.  Spindle  Celled  Sarcoma 

188 

XXXIII.  Melanotic  Sarcoma 

188 

XXXIV.   Round  Celled  Sarcoma 

188 

XXXV.   Pathology 

188 

XXXVI.  Experimental 

195 

XXXVII.  Medical  Treatment 

196 

XXXVIII.  Electrical  Treatment     . 

198 

XXXIX.  General  Surgery 

199 

XL.  Thyroidotomy    . 

204 

XLI.  Seton 

206 

XLII.  Injections 

206 

XLIII.  Cautery  , 

209 

XLIV.  Division  and  Resection  of  Isth 

UlUS 

209 

XLV.  Thyroidectomy  . 

209 

XLVI.  Intra-Glandular  Enucleation 

222 

XLVII.   Laryngotomy 

223 

XLVIII.  Exothyropexy     . 

223 

XLIX.  Ligation  of  Superior  Thyroid 

Artery 

223 

L.  Compression 

225 

LI.  Tracheotomy 

225 

ix 


Surgery  of  Hydrocephalus. 


CHAPTER. 

I. 

Aspiration. 

II. 

Lumbar  Puncture. 

III. 

Subcutaneous  Drainage. 

IV. 

Compression. 

V. 

Seton. 

VI. 

Cranial  Injection. 

VII. 

Internal  Treatment. 

VIII. 

Conclusions. 

IX. 

Pathology. 

X, 

.   Bibliography. 

I. — Surgery  of  the   Prostate. 


ANATOMY, 

The  prostate  gland  is  composed  of  two 
lateral  and  a  middle  lobe,  enclosed  in  a 
thin,  continuous  and  firm  fibrous  capsule. 
The  middle  lobe,  which  was  first  described 
by  Home  in  1806,  is  not  always  present, 
and  each  is  subject  to  anomalous  vari- 
ations. 

The  urethra  and  seminal  ducts  pass 
through  the  gland,  varying  at  times  in 
their  course.  Its  normal  size  varies  from 
one  and  one-half  to  two  inches  in  its 
transverse  diameter,  one  inch  antero- 
posterior diameter,  and  about  one  inch  in 
its  depth.  Its  weight  varies  from  one- 
half  to  one  and  a  half  ounces. 

Cowper's  glands  are  two  small  yellow 
bodies,  each  about  the  size  of  a  pea,  and 
lie  beneath  the  anterior  part  of  the  mem- 
branous urethra  close  behind  the  bulb,  en- 
closed in  the  transverse  fibers  of  the  com- 
pressor urethra-  muscle. 

It  is  composed  of  numerous  follicles ^nd 
muscular  tissue  arranged  in  such  a  manner 
as  to  form  fifteen  or  twenty  channels, 
which  constitute  the  secretory  ducts  lined 
with  columnar  epithelium,  and  open  into 
the  prostatic  urethra. 

The  follicles  secrete  a  slightly  acid, 
milky  fluid,  which  passes  through  these 
ducts  to  dilute  the  semen,  that  it  may  more 
easily  escape  into  the  urethra. 

All  vertebrates,  whether  mammals,  birds, 
reptiles  or  fish,  fecundate  in  the  same  way. 

"Seminal  fluid,  when  discharged  from 
urethra,  is  mixed  with  the  secretion  of  the 
glands  of  the  vas  deferens,  of  Cowper's 
glands,  of  the  prostate,  and  vesiculae  semi- 
nales. 

"  It  contains  water  varying  from  So  to 
90  per  cent,  in  different  animals,  serum- 
albumen,  alkali-albumen,  nuclein,  lecithin, 
cholesterin,  fats,  salt,  especially  salts  of  the 


alkaline  earths  with  sulphates,  carbonates, 
and  chlorides,  and  a  peculiar  odorous  prin- 
ciple, the  nature  of  which  is  unknown." 
(Smith). 

The  internal  pudic  gives  off"  hemor- 
rhoidal and  vesical  branches  to  nourish 
the  gland,  while  the  venous  blood  enters 
the  internal  iliac  vein  through  the  dorsal 
vein. 

Its  nerve-supply  is  from  the  hypogastric 
plexus,  and  the  filaments  of  the  sympa- 
thetic. 

ETIOLOGY. 

There  have  been  many  causes  assigned 
for  hypertrophy  of  the  prostate  in  man, 
he  being  the  only  animal  that  has  it — ex- 
cessive sexual  indulgence,  character  of 
food,  stimulants  and  gonorrhea  being  the 
most  common.  Habits  and  general  en- 
vironments of  a  certain  character  may 
greatly  influence  a  development  of  pros- 
tatic disease.  No  one  of  these  causes  has 
of  itself  been  shown  to  produce  hyper- 
trophy. One  or  all  of  them,  combined 
with  evolutionary  changes,  may  produce 
it.  Sexual  intercourse  of  any  degree  can- 
not be  the  cause,  as  prostatic  hypertrophy 
seldom  develops  in  the  negro,  with  all  of 
his  excessive  indulgence.  Otis  says  that 
hypertrophy  of  the  prostate  is  not  seen  in 
Japan,  India  or  China. 

It  seems  that  one  must  look  further  for 
the  cause  of  this  condition.  While  the 
prostate  gland  is  constant  in  mammals, 
man  is  the  only  one  in  which  the  gland 
becoms  hypertrophied  or  the  hemorrhoidal 
vessels  varicosed. 

Changing  from  quadripedal  to  bipedal, 
not  only  is  the  relation  of  the  gland  to  its 
adjacent  tissues  changed,  but  also  those  of 
the  entire  pelvic  floor.  The  rectum  un- 
dergoes a  complete  change  in  position,  and 
consequently  its  relation  to  the  prostate. 


Si'RCERr  OF  THE  PROSTATE. 


The  vascular  system  is  changed  from  a 
parallel  to  that  of  a  perpendicular  position, 
especially  the  hemorrhoidal  vessels. 

The  rectum  itself  becomes  perpendicular 
instead  of  parallel.  Constipation  is  more 
or  less  the  result  of  this  change  in  the  rec- 
tum. Varicosity  of  its  vessels  is  also  a 
result. 

The  erect  posture  of  the  body  throws 
the  weight  of  the  abdominal  viscera  greatly 
upon  the  floor  of  the  pelvis,  and  conse 
cjuently  more  or  less  upon  the  prostate  and 
rectum,  thereby  obstructing  to  some  de- 
gree the  circulation. 

Nutrition  is  impaired  and  irritation  in- 
duced, which  is  the  first  step  in  the  pro- 
duction of  pathologic  changes  in  the  gland. 
Then,  too,  why  not  infection  of  the  gland 
through  the  rectal  wall  from  the  mass  of 
feces  within  it? 

Irritation,  congestion  and  inflammation 
are  the  preliminaries  to  the  production  of 
new  tissue,  whether  they  be  produced  by 
trauma  or  infection. 

The  relation  of  prostatic  hypertrophy  to 
rectal  hemorrhoids  has  not  been  given 
much  consideration.  That  they  have  such 
a  relation  has  been  suggested  by  various 
writers. 

Hemorrhoids  are  oftener  found  in  pros- 
tatiques  than  in  prostatic  enlargement 
with  hemorrhoids.  While  the  removal  of 
hemorrhoids  has  oftener  given  much  relief, 
no  observations  have  yet  been  recorded 
concerning  the  effect  the  removal  of  the 
prostate  has  upon  hemorrhoids. 

It  is  hoped  that  those  who  are  interested 
in  the  relation  of  the  two  will  give  them 
further  consideration  as  to  their  relation 
and  causation. 

BIBLIOGRAPHY. 

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indigatis.  Bj  J.  B  Morgagni,  3  vols  ,  folio.  Ve- 
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Phil.  Trans.,  i8oq.  paper  viii.  An  Account  of 
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which  has  not  before  been  taken  notice  of  by 
Anatomists      Hj  Everard  Home,  F.  R.  S. 

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Smith.  Physiology  of  Domestic  Animals, 
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fig.  '• 

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1901,  xix,  536-588,  5,  fi<.  4,  tr. 

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Associati(  n,  April  26,  1902  Nature  of  Pros 
tatic  Hypertrophy.  Med.  Review  of  Reviews 
July  25,  1902,  p.  673. 

SURGERY. 

The  operations  for  the  cure  of  prostatic 
hypertrophy — the  removal  of  the  gland 
and  stone  in  the  bladder — being  so  similar 
in  character,  and  the  operations  for  stone 
antedating  those  for  prostatic  hypertrophy 


SCRCERV  OF  711 E  PROSTATE. 


(so  far  as  are  known  at  least  twenty-five 
hundred  years,  it  is  necessary  that  a  his- 
torical resume  of  their  respective  methods 
be  given,  that  a  better  knowledge  of  them 
may  be  had. 

Doubtless  the  various  stone  operations 
have  much  to  do  with  bringing  about  the 
removal  of  the  prostate  gland. 

Ammonius  Lithotomus,  an  Egyptian 
surgeon  of  Alexandria  (about  the  time  of 
Hippocrates,  15. C,  460-357),  invented  an 
instrument  by  means  of  which  he  broke 
down  stones  in  the  bladder  to  facilitate 
removal.  The  word  lithotomy  is  thus 
derived  from  his  name. 

Johnnes  de  Romanes,  1555,  introduced 
the  use  of  the  grooved  stick  in  lithotomy 
(Marion  operation).  An  incision  was 
made  into  the  membranous  portion  of  the 
urethra,  and  the  prostatic  portion  of  the 
urethra  was  then  either  dilated  or  rup- 
tured 

He  and  Marianus  introduced  the  prac- 
tice of  cutting  upon  the  staff  in  lithotomy 
about  1595  A.D. 

The  lateral  incision  for  stone  was  intro- 
duced by  Ran,  of  Leyden,  during  the 
seventeenth  century,  and  Frere  Jean,  1700. 

Ran  was  said  to  be  the  most  successful 
lithotomist  that  ever  lived.  He  was  taught 
his  method  by  the  celebrated  Frere  Jacques. 

Ran  kept  his  method  a  profound  secret ; 
not  even  his  favorite  pupils,  Heister  and 
Albinus,  were  able  to  learn  it.  Both 
attempted  to  describe  what  they  saw  when 
eavesdropping,  but  they  differ  in  their 
accounts. 

Roonheysen,  of  the  same  school,  men- 
tioned a  case  in  which  the  old  operations 
of  "cuttingon  the  gripe,"  or  with  grooved 
sound  and  gorget,  was  impracticable,  and 
he  was  forced  to  perform  the  supra-pubic 
operation.  This  is  probably  the  first  supra- 
pubic operation  ever  made  for  intra- vesical 
conditions. 

Paulus  Aegineta  made  an  incision  for 
lithotomy  to  one  side  of  the  raphe,  not  in 
the  centre  of  the  perineum,  as  was  the 
usual  practice. 

Senarez  tells  of  one  of  these  "cutters" 
who  introduced  an  iron  rod  into  the  penis 
until  it  met  the  stone  ;  the  latter  was  then 
removed  by  perineal  incision.  This  un- 
known is  supposed  to  have  given  John  de 
Romanes  his  idea. 

Pierre-Franco  w^as  one  of  the  most  fa- 
mous of  the  incisors. 

That  surgical  treatment  and   its  results 


upon  the  prostate  gland  may  be  better  un- 
derstood, available  bibliography  has  been 
collected  and  classified  as  herein  indicated. 
The  subject  in  general  is  so  extensive  that  . 
this  work  will  be  limited  to  the  biblio- 
graphy, chronologically  arranged,  with 
the  exception  of  the  chapter  on  surgery, 
which  will  be  made  a  special  feature  of 
this  work. 

Here,  again,  it  was  found  necessary  to 
classify  the  various  forms  of  treatment, 
which  constitute  nothing  more  or  less 
than  mechanical  and  mechanico-surgical 
methods. 

In  arraging  the  bibliography  an  attempt 
was  made  to  avoid  the  duplication  of  refer- 
ences. This,  however,  has  been  impossible 
in  many  instances.  On  the  whole,  it  is 
often  desirable  to  have  different  references 
to  the  one  title,  that  they  may  be  more 
available  and  easy  of  access. 

It  has  been  known  for  many  years  that 
the  prostate  gland  has  been  a  factor  in 
causing  obstruction  in  the  urinary  passage, 
especially  in  advanced  age.  It  has  been 
the  subject  of  attack  in  many  ways  from 
many  sources. 

That  the  surgical  technique  of  its  re- 
moval should  have  required  so  much  time 
for  its  development  remains  an  unsolved 
problem. 

The  deadly  trocar  was  used  to  enter  the 
bladder  supra-pubically,  through  the  peri- 
neum and  rectum,  its  effects  being  most 
diabolical. 

The  metallic  catheter  has  been  used  with 
similar  results,  for  in  the  majority  of  cases 
it  becomes  a  prostatic  trocar,  being  just 
a  little  more  liscensed  than  the  sharp- 
pointed,  jacketed  staff". 

The  beginning  of  serious  trouble  in 
enlargement  of  the  prostate  is  with  the 
first  introduction  of  a  catheter,  and  the 
danger  increases  with  each  successive  in- 
troduction. 

Prostatotomy,  prostatectomy  (supra- pu- 
bic, perineal  and  urethral.) — In  this  class 
of  surgery  all  operations  for  the  removal 
of  a  part,  or  all  of  one  or  more  prostatic 
lobes,  will  be  considered  ;  also  any  incision 
into  the  prostate. 

CYSTOTOMY. 

Cystotomy  has  been  done  in  various 
ways  for  many  years  for  the  relief  of  en- 
larged prostate;  supra- pubic  and  perineal 
incisions  and  punctures  have  been  made 
with  both   knife  and  trocar  with  but  little 


SURGEUr  OF  THE  PROSTATE. 


if  any  effect   upon    lessening   the   size   of 
the  gland. 

The  benefit  obtained  by  such  an  oper- 
ation is  only  palliative  by  lessening  the 
degree  of  cystitis,  which  is  always  more 
or  less  severe.  This  being  so,  cystotomy 
alone  will  receive  no  further  consideration 
at  this  time. 

MASSAGE. 

Massage  was  employed  by  Estlander  in 
1878  for  relief  of  enlarged  prostate.  Erh- 
mann  in  1891  ;  Brant,  1892  ;  Schlafka, 
1893;  and  Halberstram,  in  1893,  each  em- 
ployed and  considered  the  subject  more  or 
less  favorably.  Hogge  employed  electro- 
massage,  claiming  quite  an  innovation  in 
the  treatment  of  prostatic  enlargement. 

Lewis,  in  1899,  however,  claimed  supe- 
rior results  without  the  use  of  instruments 
(massaging  the  prostate  gland  with  the 
index  finger).  Colin,  1900,  was  of  the 
same  convictions  as  Lewis.  Kemp,  1901, 
showed  an  instrument  which  he  had  em- 
ployed for  electro-massage,  together  with 
the  applications  of  inunctions. 

Neiswauger,  1900,  employed  cataphoric 
applications  of  iodine  to  the  hypertrophic 
gland. 

INJECTION. 

Various  kinds  of  solutions  have  been 
injected  into  the  prostatic  and  testicular 
glands,  singly  and  combined,  to  reduce 
prostatic  elargement,  with  but  little 
benefit. 

Hall,  1887,  employed  argenti  nitras, 
iodine,  iodoform  and  cocaine  for  this  pur- 
pose. 

Heurate,  1896,  employed  testicular  ex- 
tracts for  injecting  the  testicle  and  pros- 
tate, separately  and  combined. 

Erwin,  1896,  injected  various  remedies 
into  the  testicles  for  the  enlargement  of 
the  prostate  gland. 

Jaboulay,  1900,  employed  rectal  medi- 
cation for  the  reduction  of  prostatic  en- 
largement. 

In  none  of  their  cases  were  the  results  sat- 
isfactory. 

LIGATION    OF    CORD. 

The  spermatic  cord,  which  is  composed 
of  arteries,  veins,  lymphatics,  nerves  and 
the  vas  deferens,  has  been  ligated  for  the 
relief  of  prostatic  hypertrophy  by  Mears, 
1894.  The  result  was  so  unsatisfactory 
that  he  did  not  repeat  the  operation  or 
advise  that  it  be  done. 


Stafford,  1895,  ligated  the  spermatic 
cord  with  but  little  if  any  benefit  to  the 
patient,  or  influence  upon  diminishing 
the  size  of  the  gland. 

•  LIGATION    OF     ILIAC    ARTERIES. 

Believing  that  hypertrophy  of  the  pros- 
tate gland  was  more  or  less  due  to  in- 
creased blood  supply.  Bier,  1893,  ligated 
both  internal  iliac  arteries  to  lessen  its 
nutrition  and  thereby,  if  possible,  cause 
atrophy  of  the  gland. 

Meyer,  1894,  was  led  to  the  same  prac- 
tice by  the  statements  of  Bier.  In  each 
case  there  was  but  slight  if  any  beneficial 
results. 

Loze,  1898,  advocated  the  removal  of 
the  venus  plexus  (vesico-)  for  enlarged 
prostate  gland. 

The  results  obtained  by  either  of  these 
procedures  did  not  warrant  further  inves- 
tigation in  their  behalf. 

VASECTOMY. 

It  was  supposed  that  the  removal  of  the 
vas  deferens  would  have  some  effect  upon 
hypertrophic  prostates,  and  while  there 
have  been  many  such  operations  recorded, 
in  which  one  or  both  have  been  excised, 
there  is  but  a  small  percentage  that  have 
been  materially  benefited,  even  for  a  short 
time. 

The  desire  to  preserve  the  ability  to 
perform  the  sexual  act  gave  vasectomy 
preference  over  emasculation,  or  destruc- 
tion of  all  the  tissues  involving  the  cord, 
whether  by  ligation  or  excision. 

The  pathology  resulting  from  vasec- 
tomy, ligation  of  the  cord  or  emasculation 
has  not  been  established. 

Division  or  ligation  of  both  vas  defer- 
ens causes  but  slight  atrophy  of  the  pros- 
tate gland.  It  is  probably  due  to  the  loss 
of  their  nerve  connection,  while  the  same 
procedure  on  the  blood-vessels  of  the  cord, 
or  cord  itself,  will  cause  atrophy  of  the 
gland;  the  testicle  becomes  disorganized. 

Sleinach,  1896,  has  shown  by  experi- 
ments on  rats  that  the  removal  of  the 
seminal  vesicles  and  prostate  gland  does 
not  lessen  the  sexual  passion  or  ability  to 
perform  the  sexual  act,  with  a  discharge 
of  spermatozoa,  but  that  fertilization  is 
prevented.  The  ability  of  the  semen  to 
fertilize  is  lessened  by  the  removal  of  their 
vesicles. 

Loumeau,  1895,  performed  this  opera- 
tion with  but  slight  effect.     Chalot,  dur- 


sriac.ERr  of  riiE  prostate. 


ing  the  same  year,  did  the  operation. 
Mears,  1895,  applied  a  ligature  to  the  vas 
deferens,  and  Ochsner,  during  the  same 
year,  resected  the  vas  deferens  for  pros- 
tatic enlargement. 

Isnardi,  1895 ;  Guelliot,  1895 ;  An- 
drews, 1896;  Floersheine,  1896;  Van- 
fritch,  1896;  Harrison,  1896;  Walton, 
1896;  Nove-Jasserand,  1896;  Isnardi, 
1S96  ;  Negretto,  1896;  Zuckerkandl,i896  ; 
Brasher,  1896;  Brown,  1896;  Bobeca, 
1896;  Nicolich,  1S96;  Freeman,  1896; 
Oliver,  1896;  Ringier,  1896  ;  Leuenstein, 
1896;  Pontier,  1896;  Pavonie,  1896; 
Kohl,  1896;  Carlier,  1896;  Brown,  1896, 
each  divided  the  vas  deferens  by  ligature, 
knife  or  excision  for  hypertrophy  of  the 
prostate  gland. 

Rissler,  1896,  injected  the  vas  deferens 
for  enlarged  prostate ;  failing  to  secure 
any  benefit,  he  later  performed  emascula- 
tion, resulting  in  much  benefit. 

White,  1896,  gave  an  exhaustive  report 
on  castration  and  vasectomy  in  the  treat- 
ment of  hypertrophy  of  the  prostate. 

Heurate,  1896,  besides  ligating  the  vas 
deferens,  injected  testicular  extract  into 
the  prostate  gland  for  hypertrophy. 

Louman,  1896,  injected  the  vas  defer- 
ens and  removed  the  testicles  for  prostatic 
enlargement. 

Wagner,  1896,  removed  the  vas  deferens 
and  testicles  for  prostatic  enlargement. 

Sherping,  1896,  was  contented  with 
simply  dividing  the  vas  deferens  for  pros- 
tatic enlargement. 

Lennauder,     1897;      Chetwood,     1897; 
Turazza,  1897;   Drezique,  1897;    Sakhar- 
off,  1897;   Bernoud,  1897;   Winter,  1897; 
Derynzhinski,    1897;     Czaplinski,    1897; 
Erdberg,  1897;   Benninghoff,  1897;  Win- 
field,  1898,  several  cases  of  castration  and 
vasectomy;     Hamonie,     1898;     Albaran, 
1898;  Yakuhonski,  1898;  Hanbarn,  1898 
Redi,    1898;    Wodarz,    1898;    Loumean 
1898;   Von  Schullen  and  Gervell,    1898 
Nicholich,    1898;     Long,    1898;     Bruni 
1898;    Harrison,    1900;     Jackson,    1900 
Desnos,    1900;     Pape,    1900;     Suetinoff, 
1900;  and  Kondinoeff,  1900,  each  made  a 
vasectomy. 

CASTRATION. 

Removal  of  one  or  both  testicles  for 
prostatic  hypertrophy  has  given  more  re- 
lief than  any  of  the  extra-capsnlar  opera- 
tions. 

There   need  be  but   slight   if   any  mor- 


tality resulting  from  it  if  a  local  anesthe- 
sia alone  be  employed.  The  fatal  cases 
have  no  doubt  been  due  to  the  use  of  gen- 
eral anesthesia,  which  should  never  be 
employed  for  this  purpose. 

The  removal  of  one  testicle  is  supposed 
to  cause  its  corresponding  prostatic  lobe 
to  undergo  atrophic  changes,  while  the 
removal  of  both  testicles  will  cause  atro- 
phy of  all  the  lobes. 

Emasculation  was  not  accepted  as  a 
remedy  for  prostatic  enlargement  until 
White  had  proven  by  experiments  upon 
animals  that  emasculation  in  the  very 
young  would  prevent  the  development  of 
the  prostate  gland,  and  that  the  removal 
of  the  testes  in  the  aged  would  cause  more 
or  less  atrophy  of  the  gland,  especially  in 
certain  forms. 

While  more  or  less  relief  has  been  given 
in  certain  cases,  there  are  many  in  which 
no  benefit  whatever  ensued. 

There  are  many  objections  to  this  oper- 
ation, but  there  are  cases,  especially  in 
the  very  old  and  feeble,  in  which  it  should 
be  done  before  subjecting  them  to  the 
more  radical  and  severe  methods  for  relief. 

Mercier,  1857,  was  perhaps  one  of  the 
first,  if  not  the  first,  to  emasculate  for 
hypertrophied  prostate.  He  records  a 
case  of  retention  of  urine  of  nine  years, 
w^ith  cure  by  excision  of  the  prostate 
gland,  followed  by  castration  and  an  oper- 
ation for  fistula  of  the  anus. 

Cabot,  1893,  records  a  case  of  castration 
for  hypertrophied  prostate. 

White,  1894,  gives  a  summary  of  the 
history  and  present  position  of  the  oper- 
ation of  castration  for  prostatic  hyper- 
trophy. 

Haynes,  1894,  performed  orchidectomy 
for  hypertrophy  of  the  prostate, 

Moullin,  1894,  wrote  on  the  treatment 
of  hypertrophy  of  the  prostate. 

Smith,  1894,  refers  to  a  case  of  obstruct- 
ive hypertrophy  of  the  prostate,  treated 
by  castration. 

Finney,  1894,  performed  double  castra- 
tion for  enlarged  prostate. 

Ricketts,  1894,  resorted  to  double  cas- 
tration for  enlarged  prostate,  with  restora- 
tion of  urethral  function. 

Meyer  and  Haenel,  1894,  report  a  case 
of  emasculation  for  enlarged  prostate. 

Lichty,  1894,  and  Thomas,  1894,  each 
record  emasculation  for  enlarged  prostate. 

Lannois,  1894,  observed  atrophy  of  the 
prostate  as  the  result  of  emasculation. 


SCRGERl'  OF  THE  PROSTATE. 


Ramm,  1894,  obtained  excellent  results 
from  emasculation  for  enlarged  prostate. 

Hayden,  1895,  made  double  castration 
for  enlarged  prostate. 

Kraemer,  1895,  reported  a  similar  case. 

Morton,  1895,  reports  a  successful  case 
of  castration  for  prostatic  hemorrhage  and 
hypertrophy. 

Norton,  1895,  speaks  of  the  effect  of 
unilateral  castration  on  the  prostate. 

Lutkins,  1895,  and  Pavoue,  1895,  each 
report  a  case  of  emasculation  for  enlarged 
prostate. 

Livings,  1895,  reports  two  such  cases. 

Lydston,  1895,  writes  on  a  recent  sur- 
gical "fad,"  castration  for  hypertrophy 
of  the  prostate. 

Roberts,  1895,  records  death  resulting 
from  castration  for  enlarged  prostate. 

Lilienthal,  1895,  and  Thayer,  1895. 
record  cases  of  castration  for  hypertrophy 
of  the  prostate  gland. 

Lezin,  1895,  noted  changes  in  the  pros- 
tate of  animals  after  castration. 

Piercy,  1895  ;  Stratton,  1895  ;  Spencer, 
1895;  Willington,  1895;  Thayer,  1S95  ; 
Pegurier,  1895,  each  report  a  case  of  cas- 
tration for  prostatic  enlargement. 

Martin,  1895  ;  Thomas,  1895,  and  Mc- 
Conkey,  1895,  each  report  emasculation 
for  enlarged  prostate. 

Bryson,  1895,  made  a  castration  for 
enlarged  prostate,  and  Alexander,  1895, 
did  a  double  orchidectomy  (with  a  protest) 
for  hypertrophied  prostate. 

Faisst,  1895 ;  Faulds,  1895 ;  Desnos, 
1895,  and  Bard,  1895,  each  record  one  or 
more  cases  of  emasculation  for  enlarged 
prostate. 

Boeckmann,  1895,  gives  a  critical  his- 
torical review  of  the  subject  of  castration 
for  enlarged  prostate.  Church,  1895,  re- 
cords a  case  of  bilateral  castration  for 
hypertrophy  of  the  prostate. 

Garin,  1895,  performed  castration  for 
hypertrophy  of  the  prostate.  Bangs,  in 
1895,  sounds  a  warning  against  castration 
for  prostatic  enlargement.  Moullin,  in 
1895,  wrote  on  some  of  the  immediate  re- 
sults produced  by  castration  in  cases  of 
enlarged  prostate.  Watson,  1895,  re- 
ported a  case  of  castration  for  relief  of 
prostatic  enlargement.  Walker,  1895,  re- 
ports seven  cases  of  double  castration  for 
relief  of  enlarged  prostate.  Bangs  wrote 
on  some  of  the  acute  chronic  conditions  of 
the  prostate  and  their  treatment. 

Among   those    who   have   done   one   or 


more  castrations  for  hypertrophy  of  pros- 
tate gland  are  : 


Koren,  1895. 
Andrews,  1895. 
Griffiths,  1895. 
White,  1895. 
Watson,  1 89;. 
Moullin.,,  1895. 
Swain,  1895. 
Souchon,  1895. 
Fleming,  1895. 
Enrue,  1895. 
Albaran,  1895. 
Roosking,  1895, 
Fenwick,  1895. 
Kane,  1896. 
Collingwood,  1896. 
Charlton,  1896. 
Chelalier,  1896. 
Bazy,  1896. 
Rice,  1896. 
Lezin,  1896. 
Farrant,  1896. 
Morton,  1896. 
Milne,  1896. 
Borelius  and  Czerny, 

1S96. 
Handly,  1896. 
Gabrielson,  1896. 
Rand,  1896. 
Byrne,  1896. 
Moullin,  1896. 
Legnen,  1896. 
vSchulten  and  Ger- 

vell,  1897. 
Carlier,  1897. 
Bazy,  Escat  and 

Chaillous,  1897. 
Jones,    1897. 
Albaran,  1897. 
Vitte,  1897. 
Eastman  n.    1897. 
Freemantle,  1897. 
Kozlovski,  1897. 
Lou  mean,  1897. 
Leghen,  1898. 
Flodorus,  1897. 


Homans,  1896. 
Pilcher,  1896. 
Bryne,  1896. 
Chavelier,  1896. 
Berezkin.  1896. 
Locin,  1896. 
Caird,  1896. 
English,  1896. 
Goldschmidt,  1896. 
Kelsey,  1896. 
Einhorn,  1896. 
Guepin,  1896, 
Tilley,  1S96. 
Palmer,  1896. 
Thomas,  1896. 
Cabot,  1896. 
Bruns,  1896. 
Southam,  1896. 
Nott,  1896. 
Murray,  1896. 
Robinson,  1896 

(a  failure). 
Meyer,  1896. 
Englisch,   1896. 
Moullin,  1896. 
Boyden,  1896. 
Tunis,  1897. 
Jones,  1898. 
Schulten,  1897. 
Carr,  1898. 
Steiner,  1898. 
Nicholson,  1898. 
Pilcher,  1898. 
Larue,  1898. 
Keyes,  1898. 
Lanz,  1898. 
Ilarmonio,  1898. 
(^uintann,  1901. 
Carlier,  1898. 
(juepin,  1898. 
Tunis,  1898. 
Rouville,  1897. 
Motz,  1898. 
Grosglik,  1S98. 


Ilorwitz,  1898,  reports  four  cases  of 
stone  in  the  bladder,  with  hypertrophy 
of  the  prostate  gland  where  positive 
diagnosis  was  impossible  until  double 
castration  resulting  in  atrophy  of  the 
prostate  rendered  the  passage  of  the  stone- 
seacher  possible. 

Hillard,  1898,  performed  castration  for 
enlarged  prostate. 


SURGERT  OF  THE  PROSTATE. 


Thompson,  1898,  castrated  for  enlarged 
prostate. 

Albaran,  1898,  made  experimental  oper- 
ations to  determine  atrophic  effects  on  the 
prostate  in  animals. 

Johnson,  189S,  made  twenty-eight  emas- 
culation for  prostatic  enlargement. 

Ricketts,  1898,  reports  nine  cases  of 
emasculations  for  enlargement  of  prostate, 

Erotozzyner,  1901,  wrote  extensively 
upon  all  the  various  operations  for  hyper- 
trophied  prostate. 

Wood  records  143  castrations;  117  re- 
covered (82  per  cent.)  ;  26  died  (18  per 
cent.);  of  the  117,  no  (94  per  cent.) 
improved,  4  not  benefited;  63  (53  per 
cent.)  the  prostate  became  smaller. 

In  his  last  92  cases  of  emasculation  for 
hypertrophy  of  prostate,  9  died,  and  66 
had  return  of  bladder  function,  and  cure 
of  cystitis. 

PROSTATOTOMY. 

One  or  more  incisions  into  the  prostate 
gland  to  cause  it  to  shrink  and  become 
smaller  have  been  accomplished  by  the 
simple  cautery,  and  various  ingeniously 
devised  instruments,  through  the  urethra, 
perineum  and  suprapubic  regions,  with  a 
considerable  degree  of  success.  They 
have  been  made  separately  and  combined. 
The  benefit  from  such  incisions  was  prob- 
ably first  noticed  in  subjects  on  whom  a 
lithotomy  was  made,  and  who  possessed 
an  enlarged  prostate,  together  with  a  stone. 
At  any  rate,  operations  for  stone  were 
known  to  greatly  benefit  prostatiques. 

Operations  for  abscess,  foreign  bodies, 
cysts,  injuries  and  pathologic  conditions 
are  included  in  this  class. 

Tenotomy  of  Levator  Prostate. — This 
operation  appears  to  have  been  first  done 
for  hypertrophy  of  the  prostate  by  Wy- 
man  in  1885.  It  was  again  done  by 
E.  W.  Andrews,  in  1902. 

There  have  not  been  a  sufficient  number 
of  these  operations  made  to  determine  its 
merits  at  this  time.  Andrews  read  a 
paper  at  the  .Saratoga  meeting  of  the 
American  Medical  Association,  1902,  in 
which  he  gave  great  promise  of  much 
benefit  resulting  from  it. 

Prostatotoniy  {uret/iral). — Incisions  of 
the  prostate  through  the  urethra  with  a 
knife  and  puncture  with  catheter,  and 
various  other  means  have  been  done  for 
many  years. 

Many  cases  treated   in   this  way  for  the 


relief  of  prostatic  enlargement  received 
more  or  less  benefit. 

It  was  this  practice,  with  its  results, 
which  induced  the  use  of  cautery  combined 
with  the  knife. 

Incision  alone  is  now  seldom  done,  it 
having  given  place  to  more  radical  meth- 
ods. 

Home,  1817,  mentions  an  operative 
procedure  upon  the  prostate  glands  through 
the  urethra. 

Costello,  1836,  describes  an  instrument 
for  incising  the  prostate  through  the 
urethra. 

Berrier,  1S50,  also  mentions  having  in- 
cised a  large  prostatic  gland  through  the 
urethra. 

Bonnet  and  Berrier,  the  same  year 
(1850),  observed  excellent  results  from 
incision  of  a  large  prostate  gland  through 
the  urethra. 

Mercier,  1857,  incised  the  prostate 
through  the  urethra  by  means  of  a  con- 
cealed knife. 

Heine,  1874,  chose  for  the  subject  of 
his  address  "The  Practical  Operation  for 
Hypertrophied  Prostate." 

Gouley,  in  1885,  incised  the  prostate 
through  the  urethra  with  a  concealed 
knife. 

Harrison,  1887,  incised  the  prostate 
through  the  perineum  for  hypertrophy  of 
the  gland  with  beneficial  results. 

GALVANO  CAUTERY. 

This  practice  has  offered  many  induce- 
ments in  the  treatment  of  prostatic  en- 
largements. Especial  hope  was  given 
when  an  instrument  was  perfected  that 
would  enable  an  operator  to  make  one  or 
more  incisions  in  its  lobes  with  more  or 
less  safety. 

In  this  way  the  prostatic  urethra  was 
supposed  to  become  functional  as  the  re- 
sult of  cicatricial  contraction.  This  prac- 
tice, which  has  been  followed  with  but  a 
slight  degree  of  success,  is  uncertain  in  its 
application  and  results,  and  accompanied 
by  a  mortality  that  should  not  be  tolerated. 

An  operation  so  severe  in  its  character, 
and  for  a  condition  from  which  one  needs 
so  much  to  be  delivered,  should  not  be 
done  away  from  the  eye  sight  of  the  oper- 
ator. 

The  per  cent,  of  cases  benefited  by  its 
use,  and  the  still  smaller  per  cent,  of  re- 
coveries, is  of  itself  sufficient  evidence  to 
condemn  it. 


SL'RGERr  OF  THE  PROSTATE. 


Rabitsch,  1875,  writes  of  Bottini's 
thermo-galvanizer,  which  Bottini  (1876) 
himself  considers  at  length.  He  again 
makes  a  plea  for  its  use  in  1S80. 

Tansini,  1882,  indorses  the  use  of  the 
cautery,  as  does  Biedert  also  during  the 
same  year. 

Alpago-Xovello,  1S83,  used  a  cautery 
needle  suprapubically. 

Bottini,  1884,  and  Musatti,  1885,  each 
speak  of  excellent  results  obtained  by  the 
cautery. 

Bottini,  1S85,  speaks  of  the  complete 
and  permanent  benefit  resulting  from  the 
use  of  the  cautery  in  prostatic  enlarge- 
ment. 

Newman,  1887,  reports  excellent  re- 
sults from  the  use  of  the  galvano-cautery 
sound  applied  especially  in  hypertrophied 
prostate. 

Roux,  18S8,  reports  having  used  the 
cautery  in  enlarged  prostate. 

Davis,  188S,  speaks  of  electrolysis  in 
morbid  alterations  that  are  produced  in 
the  prostate  by  gonorrhea  of  the  urethra. 

Casper,  1888,  reports  on  the  radical 
treatment  of  enlarged  prostate  with  the 
galvano-cautery. 

Tansini,  1888,  reports  a  permanent  cure 
of  hypertrophy  of  the  prostate  by  the  use 
of  the  galvano-cautery. 

Biedert,  1888;  Binaghi,  1889;  Roth, 
1S90;  Morotti,  1890-1891. 

Wishard,  1890  and  1902,  employed 
electro-cautery  to  incise  the  prostate 
through  a  perineal  incision,  giving  much 
relief. 

Von  Dittel,  1890,  made  a  coccygio-peri- 
neal  incision  with  more  or  less  benefit. 

Lalesque,  1890,  made  a  suprapubic 
puncture  of  the  prostate,  and  used  anti- 
septics and  lavage. 

Clarke,  1891  ;  Caprara,  1891  ;  Bottini, 
1891-1893;  Jemoli,  1893;  Bottini,  1896; 
Negretto,  1896;  Freudenborg,  1897;  Mar- 
coni, 1897;  Simon,  1898;  Weber,  1898; 
Meyer,  1898;  Bottini,  1898;  McGrane, 
1898;  Von  Frisch,  1898;  Wassidle,  1898; 
Hanc,  1898;  Lewis,  1898;  Sanesi,  1898; 
Morton,  1898;  Chassignac,  1898;  Free- 
men, 1898;  Kreissl,  1898;  Carlton,  1898; 
Motz,  1898;  Lohanstein,  1898;  Rydygier, 
1899;  Nicolich,  1899;  Downes,  1899; 
Stehr,  1900;  Newman,  1900;  Haenens, 
1900;  Lavauz,  1900;  Hogge,  1900; 
Debedat,  1900;  Cauterman,  1900;  Mc- 
Gowan,  1900;  Mynter,  1900;  Verhoogen, 
1900;     Harp,    1901,    and    Koenig,    1901, 


each  have  employed  the  galvano  cautery 
described  by  Bottini  in  prostatic  enlarge- 
ment with  more  or  less  benefit. 

Young,  1901,  made  forty  Bottini  opera- 
tions. 

Guiteras,  1901,  collected  753  prostatot- 
omies,  made  m  various  ways,  with  eighty- 
five  cures  and  forty-four  deaths. 

Bangs,  1901,  made  forty  Bottini  opera- 
tions with  three  deaths. 

Kreissl,  1901,  reports  his  work  with 
the  Bottini  operations. 

Meyer  (Lydston  Text-Book,  1900,  p. 
727)  collected  164  operations  by  the  Bot- 
tini method  from  eighteen  different  opera- 
tors. Eighty  were  cured,  forty-four  im- 
proved, twenty-six  not  improved,  eight 
deaths  due  to  the  operation,  and  six  deaths 
independent  of  operation. 

Schlagintweit,  1901  ;  Blucke,  1901  ; 
Roth,  1901;  Desnos,  1901.  and  Young, 
1901,  each  report  operations  with  the  cau- 
tery. 

Hayden,  1901,  makes  a  plea  for  conser- 
vatism in  treating  the  prostate  glands. 

Whitacre,  1901,  reported  his  experi- 
mental operations  with  the  Bottini  cau- 
tery upon  the  prostate  gland  of  dead  hu- 
man bodies.  He  demonstrated  the  cau- 
tery to  be  extremely  uncertain  in  its  re- 
sults, and  more  di'ngerous  than  any  of  the 
more  radical  prost ototomies  or  prostotec- 
tomies. 

Ransohoff,  1901,  employed  the  cautery 
knife  in  five  cases  of  prostatic  enlarge- 
ment. 

Wishard,  1902,  describes  a  new  cautery 
for  incising  the  prostate  glands. 

Kreissl,  1902,  reports  permanent  results 
failures  and  relapses  following  Bottini's 
operation  for  the  relief  of  prostatic  ob- 
struction, giving  nine  cases. 

Meyer,  1902,  reports  two  cases  of  pros- 
tatic hypertrophy  associated  with  stone  in 
the  bladder  by  means  of  litholapaxy  and 
Bottini  operation  at  one  sitting. 

Boullleur,  1902,  reports  upon  trans- 
vesical cauterization  as  a  substitute  for 
the  Bottini  operation  in  the  treatment  of 
some  forms  of  prostatic  enlargement. 

PERINEAL   PROSTATECTOMY. 

Perineal  prostatectomy  has  been  slow 
in  being  accepted  as  a  rational  operation, 
but  at  present  stands  as  the  best  surgical 
operation  for  prostatic  enlargement.  It  is 
accomplished  through  a  transverse  or  me- 
dian  incision,  similar  to  or  identical  with 


SURGERl-  OF  THE  PROSTATE. 


that  of  lithotomy.  A  part  or  all  of  one 
or  more  of  the  three  lobes  may  be  easily 
or  rapidly  removed  in  this  way.  If  pos- 
sible, their  capsules  should  be  preserved, 
the  glandular  tissue  being  separated  from 
the  capsule  with  the  finger  or  a  blunt  in- 
strument. It  is  supposed  that  hemorrhage 
is  less  if  enucleation  is  confined  within 
the  capsule.  This,  however,  is  of  little 
consequence  in  many  cases,  as  gauze  pack- 
ing around  the  drainage-tube  will  con- 
trol it.  Removal  of  the  prostate  in  cer- 
tain cases  will  no  doubt  be  done  through 
the  rectum,  especially  where  it  is  desirable 
to  use  the  rectum  for  a  urinary  recep- 
tacle. 

Gibb,  1857,  asked  the  question,  "Can 
not  enlargement  of  the  middle  lobe  of  the 
prostate  gland  be  removed  by  the  lateral 
operation  of  lithotomy  .'^" 

Bryant,  1S77,  reports  cases  of  prostatic 
tumors  removed  in  the  operation  of  lithot- 
omy. 

Luno,  1881,  records  a  case  of  prosta- 
totomy,  in  which  a  silver  tube  was  worn 
in  the  perineum  for  fifteen  months  with 
great  benefit. 

Gluck  and  Zeller,  18S1,  reported  a  case 
of  extirpation  of  enlarged  prostate. 

Eddowes,  18S4.  removed  an  enlarged 
prostatic  gland  through  a  perineal  incision. 

Stein,  1889,  also  considered  the  subject 
of  extirpation  of  the  prostate. 

Woodling,  1890,  adopted  the  operation 
of  lithotomy  for  the  prostate. 

Vignard,  1890,  performed  prostatotomy 
and  prostatectomy. 

White,  1890.  reports  two  cases  by  pros- 
tatectomy, and  Belfield,  1S90,  considered 
the  operations  on  the  enlarged  prostate, 
with  a  tabulated  summary  of  cases. 

Weir,  1891,  removed  a  hypertrophied 
prostate. 

Tobin,  1890,  wrote  on  resection  of  the 
prostate  gland  for  enlargement,  causing 
retention  of  urine. 

Reverdin,  1890,  on  the  perineal  incision 
for  prostatitis. 

Keyes,  1891,  on  the  enlarged  prostate 
and  its  operative  relief. 

Wishard,  1892.  mentions  the  perineal 
operations  on  the  prostate,  with  a  brief 
report  of  a  new  method  of  removing  the 
lateral  lobes. 

W^ishard,  1891,  enucleated  the  prostate 
through  a  perineal   intraurethral  incision. 

Pyle,  1892,  removed  the  prostate  through 
a  semilunar  perineal  incision. 


Symes,  1891,  employed  a  rubber  bulb 
in  the  bladder  for  pulling  the  prostate 
down,  that  it  might  be  removed  through 
a  perineal  incision. 

(juiard,  1900,  writes  on  the  application 
of  the  urethral  lithotomy  for  calculus  in 
the  treatment  of  prostatic  enlargement. 

Verhoogen,  1900,  mentions  a  perineal 
prostatectomy  for  enlargement  of  the 
glands. 

Thorndike,  1900,  gives  his  notes  on 
prostatectomy. 

Frayer,  1900.  gives  a  new  method  for 
performing  perineal  prostatectomy. 

Proust,  1900,  speaks  of  a  perineal  pros- 
tatectomy. 

Jabouley,  1900,  speaks  of  the  ablation 
of  the  hypertrophied  prostate. 

Roux  and  Brignoles.  1901,  write  on 
perineal  prostatectomy  totalc. 

Horwitz,  1901,  writes:  "What  have  I 
learned  from  161  operations  for  the  relief 
of  senile  hypertrophy  of  the  prostate 
gland.?" 

Gouley,  190 1,  reports  on  the  advantages 
of  the  perineal  operation,  and  a  retractor 
of  his  own  device  in  operations  upon  the 
prostate  gland. 

^^'yeth,  1 901,  advocates  the  perineal 
operation  for  enlarged  prostate  gland. 

Ferguson,  1901,  devised  an  intra-ure- 
thra-vesical  prostatic  depressor  for  sub- 
capsular enucleation,  and  morcellement 
through  the  perineum,  with  the  report  of 
nine  consecutive  successful  operations. 

Murphy,  1902,  employed  hooks  to  pull 
the  prostate  for  perineal  enucleation,  re- 
porting cases. 

Ricketts  (B.  Merrill),  1902,  removed 
the  prostate  gland  in  its  entirety,  includ- 
ing its  capsule,  through  a  transverse  peri- 
neal incision  in  two  emergency  cases. 

Case  of  Dr.  y.  O.  Blackerby. — Case 
sixty-seven  years  old,  troubled  for  several 
years  with  difficult  urination.  Passed 
daily  from  50  to  140  ounces  of  thick  urine 
and  mucus.  He  used  a  small  soft  rubber 
catheter  for  several  months.  Lost  about 
forty-five  pounds  in  weight  during  last 
eight  months  ;  was  told  that  he  could  not 
recover;  settled  his  business  aff"airs  and 
went  to  bed  prepared  to  die.  After  hav- 
ing been  confined  to  bed  for  two  weeks 
I  made  a  transverse  perineal  incision  to 
attack  the  prostate,  which  was  small  and 
hard,  the  left  lobe  larger  than  the  right. 
It  was  impossible  to  remove  either  one  of 
its   lobes,  owing  to  the  firmness  of  their 


SUnaERT  OF  THE  PROSTATE. 


structure.  The  urethra  was  very  small, 
not  permitting  the  introduction  of  a  sound 
of  any  size,  even  though  a  small  rubber 
Nelaton  catheter  had  been  used  for  some 
time.  It,  however,  did  not  remove  the 
mucus ;  only  the  thin  watery  portion  of 
the  urine  would  pass  through  it.  It  was 
decided  to  remove  the  gland  in  its  en- 
tirety, with  its  capsule.  In  doing  so  it 
was  not  necessary  to  ligate  or  torsion  a 
blood-vessel.  A  large  silver  tube,  similar 
to  the  letter  "S,"  was  introduced  and 
secured  by  gauze  packing.  Temperature 
remained  normal  nearly  all  of  the  time 
since  the  operation.  He  has  made  an  un- 
interrupted recovery  with  the  use  of  the 
silver  tube  remaining  in  the  perineum. 
He  has  regained  much  of  his  flesh  and 
general  health. 

Case  II. — Aged  seventy-seven,  patient 
of  Dr.  Wm.  Moore,  of  Ironton,  Ohio. 
Small,  poorly  nourished.  Used  silver 
catheter  about  two  years.  June  4,  1902, 
in  attempting  to  introduce  it,  he  pene- 
trated the  body  of  the  prostate  twice  and 
lacerated  the  wall  of  the  rectum.  I  saw 
him  twenty  hours  after  this  occurred ; 
blood  was  passing  from  the  rectum  and 
penis,  A  catheter,  hard  or  soft,  could 
not  be  introduced  into  the  bladder.  A 
transverse  perineal  incision  was  made  and 
the  entire  prostate,  with  its  capsule,  re- 
moved, with  bleeding  of  little  consequence 
and  without  the  necessity  of  ligating  or 
torsioning  a  blood-vessel.  A  silver  tube 
not  being  at  hand,  the  wound  was  packed 
with  gauze  until  forty-eight  hours  after, 
when  a  letter  of  "  S  "  silver  tube  was  in- 
troduced and  retained  with  gauze  pack- 
ing. The  contents  of  the  bowels  have 
continued  to  escape  through  the  wound. 
The  passage  of  urine  through  the  urethra 
will  never  be  re-established  in  this  case. 
July  24,  the  urine  passes  directly  into  the 
rectum. 

The  use  of  the  rectum  as  a  receptacle 
for  urine  in  cases  where  the  urethra  can- 
not re-established  is  desirable,  and  should 
be  accomplished  in  many  cases. 

October  10,  1902.  Rectum  is  now  the 
urinary  receptacle.  Urinates  about  every 
five  hours  by  rectum.  Perineal  opening 
almost  closed.  The  same  will  be  accom- 
plished in  the  first  case. 

Dr.  W.  W.  Keen,  in  a  personal  con- 
versation, relates  the  case  of  a  woman 
who  utilized  her  rectum  for  the  urinary 
receptacle   for   twenty-two  years,  necessi- 


tated by  the  loss  of  the  base  of  the  bladder 
in  prolonged  confinement. 

If  the  rectum  has  been  so  utilized  in 
man  the  record  has  been  overlooked. 
However,  there  seems  to  be  no  reason 
why  it  should  not,  especially  if  the  fistu- 
lous tract  be  short. 

Whether  it  be  short  or  long,  there  is  a 
possibility  of  one  or  more  channels  (other 
than  the  primary  one)  forming  to  estab- 
lish perineal  openings,  and  thereby  cause 
much  trouble  and  inconvenience. 

The  formation  of  these  channels  would 
no  doubt  be  the  result  of  stenosis  of  the 
©riginal  opening  into  the  rectum,  the 
possibilities  being  proportionate  with  the 
length  of  the  channel. 

If  the  base  of  the  bladder  could  be 
united  to  the  rectum  these  difficulties 
would,  no  doubt,  be  overcome;  also  the 
necessity  for  any  perineal  opening. 

There  being  no  resistance  to  the  escape 
of  urine,  the  muscular  fibres  of  the  bladder 
contract  and  become  atrophied  to  such  a 
degree  as  to  enable  it  to  retain  but  one  or 
two  ounces  or  less  of  fluid,  a  condition  to 
be  desired,  as  there  is  a  possibility  of 
feces  accumulating  within  it. 

There  is  the  same  danger  of  kidney  in- 
fection from  a  vesico-rectal  fistula  as 
where  the  ureters  are  implanted  into  any 
other  portion  of  the  alimentary  tract. 

SUPRAPUBIC    PROSTATECTOMY. 

This  operation  includes  all  measures 
for  the  removal  of  a  part  or  all  of  the 
prostate  glands  suprapubically. 

Roonhysen,  in  his  work  on  cutting  on 
the  gripe,  or  with  grooved  sound  and 
gorget,  was  impracticable,  and  he  was 
forced  to  perform  the  suprapubic  opera- 
tion for  stone.  This  probably  is  one  of  the 
first  of  suprapubic  operations. 

Suprapubic  prostatectomy  has  for  sev- 
eral years  been  more  extensively  employed. 
It  was  purely  an  intravesical  operation, 
intended  especially  for  the  removal  of  the 
middle  prostatic  lobe. 

There  were,  however,  many  objections 
to  it,  some  of  which  are  :  first,  difficult 
drainage;  second,  difficult  manipulation; 
third,  difficulty  in  controlling  hemorr- 
hage. 

Then,  too,  the  mortality  was  about  20 
to  30  per  cent.  The  smaller  tumors  and 
undersized  prostate  were  not  reached  by 
this  operation.  It  was  only  the  larger 
growths,  especially  of  the  middle  lobe,  to 


SURGERr  OF  THE  PROSTATE. 


which  the  method  is  applied  with  any  de- 
gree of  satisfaction. 

Lisrink,  1882,  extirpated  a  large  pros- 
tatic gland  suprapubically, 

Harrison,  1SS3,  records  a  case  of  direct 
exploration  of  the  bladder  and  removal  of 
a  large  prostatic  tumor  by  the  suprapubic 
method. 

Belfield,  1S86,  enucleated  the  prostate 
gland  through  a  suprapubic  incision. 

Edwards,  18S5.  records  a  prostatectomy 
(Mercier's  operation)  for  complete  ob- 
struction to  micturition. 

Groves,  1887,  considers  prostatotomy, 
with  report  of  case. 

Atkinson,  1888,  removed  portions  of  a 
large  prostatic  gland  suprapubically  by 
AIcGili's  method. 

AIcGill,  1888,  reports  three  cases  of 
suprapubic  prostatectomy. 

Rouchand,  1 888, wrote  extensively  upon 
surgical  intervention  in  treating  hyper- 
trophied  prostate. 

Browne,  1888,  records  a  suprapubic 
prostatectomy. 

Obalinski,  1889,  reports  a  radical  cure 
of  retention  of  urine  from  enlargement  of 
the  prostate  gland  by  prostatectomy. 

Delageniere,  1889,  wrote  upon  hyper- 
trophy of  prostate  and  the  various  pos- 
sible routes  for  the  extirpation  of  its  lateral 
lobes. 

Cabot,  1888,  records  two  cases  of  pros- 
tatotomy for  obstruction. 

Kummell,  1889,  wrote  extensively  on 
the  operative  treatment  of  hypertrophy 
of  the  prostate,  as  did  Helferick,  also  in 
the  same  year. 

Lane,  1889,  excised  the  middle  lobe  for  a 
considerable  hypertrophy;   death  ensued. 

The  Boston  Medical  Journal.,  1889, 
records  a  suprapubic  prostatectomy  in  a 
patient  sixty-nine  years  old  ;   recovery. 

Robson,  1S89,  records  a  prostatectomy 
as  a  sequel  to  the  operation  of  suprapubic 
lithotomy. 

Drake-Brockman,  1889,  records  a  case 
of  suprapubic  prostatectomy  (McGill's 
operation)  for  enlarged  prostate. 

Zuckerland,  1889-91,  reports  a  case  of 
prostatotomy. 

Southam,  1890,  reported  a  case  of 
suprapubic  prostatectomy  for  retention  of 
urine. 

Post,  1891,  records  a  prostatotomy  in  a 
patient  of  forty-two  years. 

Kuster,  1891  ;  vStewart,  i89i,each  re- 
cord a  case  of  prostatectomy. 


Cameron,  1891,  removed  large  masses 
of  a  prostatic  tumor  suprapubically. 

Tobin,  1891,  records  a  case  of  prosta- 
tectomy for  senile  enlargement. 

Wishard,  1893,  writes  on  the  palliative 
and  operative  treatment  of  enlarged  pros- 
tate. 

Lewis,  1893,  records  a  prostatectomy  for 
enlarged  prostate,  with  recovery  of  power 
to    urinate   voluntarily;     pyelitis;    death. 

Adams,  1893,  gives  a  report  of  three 
prostatic  tumors  removed  by  Dr.  Arm- 
strong, of  Montreal. 

Home,  1893,  gives  a  case  of  hypertro- 
phy of  the  middle  lobe  of  the  prostate ; 
successful  removal  by  the  suprapubic 
method. 

AlouUin,  1893,  mentions  the  operative 
treatment  for  enlargement  of  the  prostate. 

Hutchinson,  1892,  records  a  case  of 
prostatectomy  for  bladder  obstruction. 

Keys,  1893,  speaks  of  an  efficient 
method  of  controlling  hemorrhage  after  a 
suprapubic  prostatectomy. 

Pyle,  1892,  mentions  a  new  method  for 
removing  the  prostate  gland. 

JuUin,  1893,  records  a  case  of  cystotomy 
and  prostatectomy  for  gland  enlargement. 

Hays,  1893,  advocated  suprapubic  fis- 
tula. 

White,  1893,  wrote  on  the  present  posi- 
tion of  the  hypertrophied  prostate,  as  did 
Broome  also. 

Broome  also  wrote  (1893)  on  the  ra- 
tional treatment  of  prostatic  enlargement 
in  old  men. 

Clagg,  1893,  gave  some  notes  on  the 
operative  treatment  of  enlarged  prostate. 

Schmid,  1893,  records  a  prostatectomy. 

Barling,  1893,  recorded  a  case  of  pros- 
tatectomy performed  twice  on  the  same 
patient,  the  second  time  with  complete 
success. 

Gervais  de  Rauville,  1893,  wrote  on  the 
surgical  intervention  in  hypertrophied 
prostate. 

Brown,  1893,  wrote  on  suprapubic 
prostatectomy,  and  Desnos  on  cystotomy 
in  prostatiques. 

Van  Hook,  1893,  records  two  prosta- 
tectomies. 

Pousson,  1894,  considers  the  various 
partial  prostatectomies. 

Briddon,  1893,  also  considers  prosta- 
tectomy by  suprapubic  incision. 

Bron,  1894,  writes  on  the  surgical  treat- 
ment of  prostatiques. 

Lydston,  1894,  writes  on  prostatectomy. 


SURGER7-  OF  THE  PROSTATE. 


n 


McKinnon,  1894,  reports  three  cases  of 
McGill's  operation  for  prostatic  enlarge- 
ment. 

Moullin,  1894,  asks  the  question:  Can 
atrophy  of  the  enlarged  prostate  be  in- 
duced by  partial  removal  ? 

Nicoll,  1894,  considers  a  method  of  ex- 
cising the  prostate. 

Romme,  1894,  writes  about  cystotomy 
and  cysto-drainage  in  prostatiques. 

Robson,  1894,  reports  a  series  of  twelve 
cases  of  McGill's  suprapubic  prostatec- 
tomy. 

Bryson,  1895,  gives  a  tabulated  report 
of  twenty-seven  operations  for  prostato- 
myomectomy  by  the  suprapubic  route. 

Cox,  1895,  records  a  case  of  removal  of 
the  middle  lobe  of  the  prostate  in  a  man 
seventy-six  years  of  age. 

SutclifFe,  1895,  reports  a  case  of  prosta- 
tectomy and  encysted  calculi,  with  re- 
marks and  chromolithograph. 

White,  1895,  gives  his  recent  experi- 
ences in  hypertrophied  prostate. 

Fuller,  1895,  records  six  successful  and 
successive  cases  of  prostatectomy,  supra- 
pubic. 

Woolsey,  1895,  gives  some  considera- 
tions on  prostatectomy. 

Little  wood,  1896,  records  a  case  of 
suprapubic  prostatectomy  (McGill's  oper- 
ation) illustrating  a  method  of  arrest  of 
hemorrhage  by  packing  the  bladder  with 
a  roll  of  gauze. 

Alexander,  1896,  writes  on  prostatec- 
tomy. 

Halliday,  1896,  records  a  case  of  en- 
larged prostate  removed  by  suprapubic 
prostatectomy. 

H<>tchki>-s,  1897,  reports  two  successful 
ca^es  of  prostatectomy. 

Robson,  1897,  a  case  of  suprapubic 
prostatectomy,  with  subsequent  history  of 
the  patient. 

English,  1897,  considers  prostatectomy, 
a-  does  Koehler  also  (1897). 

Chown,  1897,  gives  his  notes  in  three 
cases  ol  prostatectomy. 

Crnig,  1898,  gives  his  notes  on  a  case  of 
proslii'ectomy. 

McKinnon,  1898,  made  a  suprapubic 
prostatectomy. 

Tunis,  1898,  records  a  case  of  hyper- 
trophy of  the  prostate  gland  in  a  man 
seventy-eight  years  old,  six  days  after 
castration. 

Hinder,  1898,  records  four  cases  of 
prostatectomy. 


Pyle,  1898,  gives  title  of  paper,  "Pros- 
tatectomy :   A  Claim  of  Priority." 

Andrews,  1898,  considers  at  length  the 
four  new  operations  for  prostatic  enlarge- 
ment. 

Syms,  1899,  briefly  considers  perineal 
prostatectomy,  reporting  nine  cases,  all 
recovering,  eight  of  which  had  complete 
restoration  of  function. 

Pasquion,  1900,  mentions  a  suprapubic 
prostatectomy. 

Guiteras,  1900,  writes  on  the  status  of 
the  treatment  of  hypertrophy  of  the  pros- 
tate in  the  United  States.  He  collected 
153  prostatectomies  made  in  various  ways  ; 
no  recovered  (72.3  per  cent.)  ;  25  deaths 
(16.4  per  cent.);  17  failures  (11. 2  per 
cent.), 

Minter,  1900,  makes  remarks  on  the 
technique  of  prostatectomy. 

Clarke,  1900,  advocated  two  stages  of 
suprapubic  operations  for  enlarged  pros- 
tate, reporting  seven  cases,  although  Senn 
advocated  two  sittings  for  removal  of  stone 
in  1894. 

Hawkes,  1900,  records  a  case  of  supra- 
pubic and  submucous  prostatectomy. 

Young,  1901,  had  two  deaths  in  fifteen 
suprapubic  prostatectomies.  He  says  that 
eleven  were  complete  enucleations. 

McRae,  1901,  reports  three  successful 
suprapubic  prostatectomies. 

COMBINED    PERINEAL    AND    SUPRAPUBIC 
PROSTATECTOMY. 

There  are  many  advantages  in  making 
both  a  suprapubic  and  perineal  incision 
for  the  purpose  of  removing  the  prostate 
gland,  especially  where  there  is  doubt  as 
to  the  intravesical  conditions,  or  securing 
perfect  drainage,  whether  the  drainage  is 
through  an  unopened  urethra,  a  perineal 
opening,  or  into  the  bladder. 

Fuller,  1895,  removed  a  prostate  gland 
by  the  combined  method  and  draiged  both 
ways. 

Nicoll,  1895,  made  a  perineal  enuclea- 
tion, with  counter- pressure  from  above 
through  open  open  bladder.  Drainage  in 
his  case  was  through  a  catheter  retained 
in  the  unopened  urethra. 

Alexander,  1896,  removed  the  gland 
through  the  perineum  (intraurethral), 
with  counter-pressure  from  above  through 
open  bladder.  Drainage  was  secured  both 
ways.  However,  he  prefers  the  perineal 
route  for  the  removal  of  the  prostate. 

Watson,  1898,  records  a  prostatectomy 


SCRCiERr  OF  THE  PROSTATE. 


by  the  combined  method  of  suprapubic  and 
perineal  incision.  Recovery  resulted,  with 
complete  restoration  of  bladder  function. 

Bryson,  1899,  performed  a  perineal  sub- 
capsular enucleation,  with  a  suprapubic 
prevesical  incision  (did  not  open  bladder) 
for  counter  pressure.  Drainage  through 
the  perineum. 

Syms,  1899,  enucleated  the  gland 
through  a  perineal  incision,  making  coun- 
ter-pressure through  an  epicystic  incision 
into  the  peritoneum. 

Guiteras,  1901,  mahe  a  suprapubic  enu- 
cleation of  the  gland,  making  counter- 
pressure  with  the  finger  in  the  rectum. 
He  drained  from  above  and  below. 

ABSCESS   (1824-1902). 

Abscess  of  the  prostate  gland  is  quite 
common,  and  due  to  many  causes,  princi- 
pally injury  and  gonorrhea.  The  most 
frequent  exit  of  pus  is  by  rupture  into  the 
bladder,  although  it  frequently  ruptures 
into  the  rectum.  There  is  no  special  dif- 
ference either  way,  one  being  almost  as 
serious  as  the  other,  single  or  multiple, 
usually  the  latter. 

There  is  more  or  less  fever,  with  great 
pain  and  tenderness  upon  pressure  through 
the  rectum.  An  incision  should  be  made 
into  the  gland  and  through  the  perineum 
as  soon  as  there  is  the  slightest  indication 
of  pus  being  present. 

Cysts  of  any  character  within  the  pros- 
tate may  bt-coine  infected,  as  may  also 
blood-clots  contained  therein.  Prostatic 
stones,  caliareous  deposits  or  foreign 
bodies  of  any  character  may  become  in- 
fected and  rrsult  in  an  abscess. 

Abscess  and  foreign  bodies  should  be 
removed  by  perineal  incision  (raphe). 
Many  such  operations  have  been  made; 
also  puncture  of  abscess  through  rectum. 

Segond  collected  114  cases  of  prostatic 
abscess,  with  34  deaths,  10  permanent 
fistuljE  ;  yo  recovered. 

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1895;   Wien.  1897.  iv  pt.,  ii,  111-113 

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244-254. ■ 

Guiard,  F.  P.     J.  med.,  Paris,  1900,  xi,  9  12. 

Guiteras,  R.  Therap.  Gaz.,  Detroit,  1900. 
xvi,  73-82. 

Saint  Cene,  A.  Delhypertrophie  prostatique, 
Paris,  1900,  69  pp. 

Lamole,  M.  Toulouse  Imp.  St.  Cyrien,  1900, 
No.  375,  76  p. 

Moller,  M.  Centralbl.  f.  d.  krankh.  harn-u. 
sex-org.  Lpz  ,  1901,  xii,  157162. 

Ricketts,  B.  Merrill.  Incised  prostatic  abscess 
in  two  cases  through  the  rectum  and  one  through 
a  perineal  incision  ;  recovery  in  each. 

TUBERCULOUS    PROSTATE. 
(1836-I9O1). 

Tuberculosis  attacks  the  prostatic  gland 
in  the  same  way  as  it  does  other  tissues. 
It  seldom  originates  in  the  glandular  tis- 
sue, so  that  primary  tuberculosis  is  rare. 
The  secondary  form  is  more  frequent.  .  It 
may  be  caeseous  or  undergo  cystic  degen- 
eration, and  open  in  any  direction.  The 
disease  may  confine  itself  to  the  gland  or 
extend  into  the  neighboring  tissues.  Its 
most  thorough  and  radical  removal  should 
be  done  as  soon  as  possible  after  its  dis- 
covery.   It  was  first  described  by  Louis. 

Little  has  been  done  in  this  class  of 
cases,  but  much  is  to  be  gained  by  active 
surgical  treatment,  with  reference  to  its 
complete  removal. 

niHLIOGRAPHY. 

Annales  de  chirurgie,  1845  (Vidal  de  Cassis). 
Large  tuberculous  cavity. 

L' Union  Medicale,  1850  (Ditto).  Large 
tuberculous  masses. 

Lancet,  vol.  i,  1850,  p.  290  Mr.  Simon  men- 
tions a  case  in  which  the  entire  genitourinary 
tract  was  more  or  less  affected  with  tubercular 
deposits. 


i6 


SURGERV  OF  THE  PROSTATE. 


Pigeaux,  H.  J.  Univ.  et  behd.  de  med.  et  chir. 
prat.,  Paris.  183  .  ii,  365-369. 

Viard.  Bull.  soc.  anat.,  Paris,  1847,  xxii, 
330  332. 

Burchardt,  I.     Vratislavis,  1856. 

Guerlain.     Bull.  soc.  anat  ,  Paris,  i860,  xxxv, 

133- 

Obedenare.  Bull.  soc.  anat.,  Paris,  1861;,  x, 
636. 

Delfau,  B.  A.  G.     Paris,  1874. 

Eschaquet.     Bull.  soc.  anat.,  Paris,  1874.,  xlix, 

54^- 

Garin.  Ann.  soc.  de  med.  de  St  Etienne  et 
de  la  Loire  (1872  75),  1876,  C    262  273. 

Jamin,  R.     Bull.   soc.   anat.,  Paris,   1882,  vii, 

54-57- 

Lycops.  Arch.  med.  beiges,  Brux,  1884,  xxvi, 
163-168. 

Bouilly.  Bull,  et  mem.  soc.  de  chir.,  Paris, 
1885,  xi,  576  578. 

Rich.  Liverpool  Med.  Chir.  Journal,  1885, 
V,  219. 

Stonham,  C.  Tr.  Path.  Soc,  London,  1887  8, 
xxxix,  197. 

Sarda,  H.  Arch.  prov.  de  chir.,  Paris,  1900, 
ix,  177-190. 

Marwedel,  G.  Beitr.  z.  klin.  chir.  Tubing., 
1892    ix,  537  576. 

Desnos,  E.  Cong.  pi.  etude  de  la  tuberculeuse 
1893,  Paris,  1894,  i">  ^^9- 

Zmke,  E.  B.  Paris,  1894.  Thesis:  Trait. 
Des  Abces  Tuberculeux. 

Gaudier,  H.  Ann.  d.  mal.  d.  org.  genito  urin., 
Paris,  1895,  xiiii  125-132. 

Lane,  W.  A.  Tr.  Clin.  Soc,  London,  1895, 
xxviii,  288-290. 

Hannemann,  F.  ]\L     Kiel.  1895,  19  pp. 

English,  J.     Wiener  klinik,  1S96,  xxii,  17. 

Fuller,  E.  Journal  Cutan.  and  Genito-Urin. 
Dis.,  New  York,  1N97,  xv,  457-462. 

Duean,  W.  C.  Report  to  the  Louisville  Clin- 
ical Society.  Southern  Med.  Record,  Atlanta, 
1898,  xxviii,  292-295. 

Meyer  and  Hanei,  1893. 

De  la  tuberculose  genitale.  Gaz.  Med.  de  Paris, 
No.  25,  1892. 

Baumgarten.  Centrabl.  f.  chir.,  July  20,  1901 
— supplement. 

HYDATID     CYSTS     (1846-I9O1). 

Echinococci  are  found  more  frequently 
in  the  prostate  gland  than  any  of  the 
animal  parasites.  They  are  usually  pri- 
mary, but  may  be  secondary  in  their  origin. 
The  cyst  may  rupture  into  the  rectum, 
bladder  or  peritoneal  cavity.  If  into  the 
rectum  or  bladder,  spontaneous  recovery 
may  ensue  ;  if  into  the  peritoneal  cavity, 
death  may  follow  or  the  parasites  may 
become  rl-encysted  retro-peritoneally,  or 
within  the  peritoneal  cavity,  without  seri- 
ous results  so  far  as  the  primary  rupture 
of  the  glandular  cyst  is  concerned.  If 
possible,  the  glandular  cyst  should  be 
reached  through  the  perineum  as  soon  as 
detected  and  before  rupture. 


BIBLIOGRAPHY. 

Lowdell,  G.  Med.  Times,  London,  1846,  xiv, 
199. 

Englisoh,  J.     Med.  Jahrb.  VVien,  1873   71-76. 

Planty-Mouxion,  E.     Paris,   1878. 

Butruille,  H.  Bull.  soc.  anat.,  Paris,  1878,  iii, 
265-267. 

Mallez.   France  med.,  Paris,  1878,  xxv,  258-260. 

Le  Dentu.  Bull,  et  mem.  soc.  chir.,  Paris, 
1879,  V,  27. 

Tillaux.  Bull,  et  mem.  soc.  de  chir.,  Paris, 
1883,  ix,  143-146. 

Nicaise,  Dr.  Millet.  Bull,  et  mem.  soc.  de 
chir,  Paris,  18K4,  x,  551  559. 

Winterberg,  W.  Med.  News,  New  York,  1896, 
lixix,  521-523. 

Bangs,  L.  B.  Ann.  Surg.,  Philadelphia,  1901, 
xxxiii,  565- 573. 

PROSTATIC     CALCULI     (1843-I9O1). 

Concretions  may  form  in  the  prostatic 
ducts,  to  be  retained  or  discharged  into 
the  urethra.  Those  retained  may  be- 
come large  and  encysted  in  the  prostatic 
tissue. 

Fuller  reports  such  an  one,  weighing 
three  ounces.  The  smaller  ones  may  be 
expelled  into  the  urethra,  and  then  back- 
ward into  the  bladder,  to  subsequently 
pass  out  of  the  urethra,  or  to  form  the 
nucleus  of  a  cystic  stone  or  pass  forward 
out  of  the  urethra. 

This  variety  vary  in  size  from  that  of  a 
millet  seed  to  a  grain  of  wheat. 

BIBLIOGRAPHY. 

Smith.  Dublin  Journal  Medical  Science,  1843, 
xxiii,  163. 

Mussey.  W.  H.  Tr.  Am.  Med.  Assn.,  Phila- 
delphia, 1872,  xxiii,  521,  I  pi. 

Jean,  A.  Bull.  soc.  anat.,  Paris,  1878,  iii, 
102-105. 

Teeven.  W.  F.  Proc  Med.  Soc.  London, 
1879  81,  V,  67. 

Picque,  L.  Bull.  soc.  anat.,  Paris,  1883,  Iviii, 
442. 

Clarke,  W.  B.  Tr.  Path.  Soc,  London,  1888-9, 
xl,  179-181. 

Venzikovski.  J.  L.  Ejened  klin.  gaz  St.  Peters- 
burg, 1888,  viii.  277,  309. 

Psalidas.  Gaz.  med.  d'orient,  Constantinople, 
1890-1,  xxxiii.  168-171. 

Bangs.  L.  B.  Med.  News,  New  York,  1896, 
Ixviii,  657  659 

Herescu  et  Cottet.  Bull.  soc.  anat.,  Paris, 
1898,  Ixxiii,  645-657. 

Goldine-Bird,  C.  H.  Brit.  Med.  Journal,  Lon- 
don, 1898,  ii,  129  132. 

Bardesco.  Bull,  et  mem.  soc.  de  chir.,  Buca- 
rest,  1900,  iii,  98-101. 

Spencer,  J.  C.  Philadelphia  Med.  Journal, 
1900,  vi,  457  460. 

Loumeau,  E.  Ann.  de  la  policlin.,  B  rdeaux, 
1900,  xii,  14-16 

Pasteau,  O.  Ann.  d.  mal.  d.  org.  genito  urin., 
Paris,  1901,  xix,  416-432,  16  tig. 


SURGER2'  OF  THE  PROSTATE. 


17 


CARCINOMA    OF    THK    PROSTATE 
(1833-1902). 

Malignant  neoplasms  of  the  prostate 
gland  are  not  uncommon,  and  are  more 
frequent  in  advanced  age  and  childhood, 
rarely  under  fifty  years.  They  may  be  of 
primary  or  secondary  origin,  more  fre- 
quently secondary,  and  more  often  in  the 
aged  and  in  the  white  than  the  black 
races,  and  especially  more  frequent  with 
the  civilized  than  the  uncivilized,  consti- 
tuting about  80  per  cent,  of  malignant 
growths  of  the  prostate. 

Carcinoma  i«  the  most  common  form, 
and  usually  primary,  only  occasionally 
secondary.  It  usually  originates  in  the 
mucosa  of  the  prostatic  urethra,  gradually 
involving  a  portion  or  all  of  the  prostatic 
gland  or  its  surrounding  tissues.  It  is 
usually  of  rapid  growth,  and  may  undergo 
cystic  degeneration  at  any  time  in  the 
course  of  its  developmect. 

Its  removal  is  uncertain  and  unsatisfac- 
tory, and  should  not  be  attempted  unless 
in  the  very  earliest  development. 

BIBLIOGRAPHY. 

Beling.     Arch.   f.   med.   erfarh.,  Berlin,   1822, 

i.  443-457- 

Walton,  H.  Tr.  Path.  Soc,  London,  1846  8, 
287  289. 

Mann,  J.  Med.  Times  and  Gaz.,  London,  1862, 
I,  105x07. 

Thompion,  H.  Tr.  Path.  Soc,  London,  1853-4, 
V,  204-207,  I  pi. 

Heyfelder,  J.  F.     Deutsche  klinik,  Berlin, 1885, 

vii.  505- 

Herzfelder,  H.  Ztschr.  d.  k.  k.  gesellsch.  d. 
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Isaacs.     N.  Y.  Med.  Times,  1856,  v,  169. 

Aschenb«rn,  O.  Arch.  f.  klin.  chir.,  Berlin, 
1880,  XXV,  327. 

Schottelius,  M.  Ein  fall  von  primarencarcinom. 
der  prostata.  Schrift  d.  gesellsch.  z.  Bedford 
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32-37- 

Barton.     Dublin  Journal  Med.  Science,  1881, 

l"i,  553- 

Boyd,  S.  Tr.  Path.  Soc,  London,  1881-2,  xxxiii, 
200  203,  I  pi. 

Bubb.  British  Med.  Journal  London,  1881, 
i,  849. 

Wesseler,  F.  W.  St.  Louis  Med.  and  Surgical 
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Odwald,  R.  J.  W.  Med.  Times  and  Gaz., 
London,  1883,  11,423;  abstract  of  a  clinical  lec- 
ture on  a  case  where  a  scirrhous  carcinoma  of 
the    prostate    was   removed,    Lancet,    London, 

1884,  ii,  483. 

Clarke,  W.  B.  Tr.  Path.  Soc,  London,  1884-5, 
xxxvi,  289. 

Favell  and  Jackson.     Tr.  Path.   Soc,  Lodon, 

1885.  i  843. 

Guyon.     Bull,  med.,  Paris,  1837,  i,  1339,  1375. 


Maylard,  A.  E.  Glasgow.  Med.  Journal,  1887, 
xxvii,  374377. 

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(1886  77),  1887,  xxxviii,  195. 

Maylard.  Tr.  Glasgow  Path,  and  Clin.  (1886- 
1891),  i8qj,  iii,  21-23. 

Exner,  Kurt.  Griefswald,  1892,  31  p.;  i  fall 
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1894,  *^^- 

Sasse,  F.  Arch.  f.  klin.  chir.,  Berlin,  1894, 
ilviii,  593  606. 

Morte.     Gaz.  d.  osp.  Milano,  1895,  xvi,  ion. 

Dubuc.     France  med.,  Paris,  1895,  xlii,  465  467. 

Carless,  A.  King's  Coll.  Hosp.  Reports, 
1884  5.  London,  1896,  ii.  88. 

De  Rouville,  G.  Bull.  soc.  anat.,  Paris,  1896, 
Ixxi,  534. 

Herlemont,  G.  E.     Lille,  1896,  28  p. 

Beyer,  G.  B.  A.     Griefswald,  1896,  33  p. 

Redtenbacher,  L.  Jahrb.  d.  Wien.  k.  k.  krank- 
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Tailhefer,  E.  Gaz.  hebd.  de  med.,  Paris,  1897, 
ii,  805. 

Albarran  et  Holle.  Compt.  rend.  soc.  biol., 
Paris,  V,  722725. 

Cone.  S.  M.  John  Hopkins  Hosp.  Bull.,  Balti- 
more, 1896,  ix,  114, 118. 

Bamberger,  L.  Inaug.  diss.,  Wurzburg,  1900, 
Juli-Dezember. 

SARCOMA    OF    THK    PROSTATE. 
(1853-I902). 

Sarcoma  is  less  frequent,  hard  and  slower 
in  its  growth.  It  usually  originates  in  the 
cortical  substance,  and  of  any  type.  There 
may  or  may  not  be  pain,  and  seldom  hem- 
orrhage until  greatly  advanced.  Usually  in 
young  subjects. 

The  growth  may  develop  in  any  direc- 
tion, usually  in  the  direction  of  least  resist- 
ance. For  that  reason  the  growth  usually 
extends  upward  (opposite  to  the  triangular 
ligament) . 

Spanton,  1882,  removed  a  large  sarco- 
matous tumor  of  the  prostatic  gland  with 
fatal  results.  The  removal  of  a  sarcoma- 
tous prostate  offers  much  in  the  way  of 
relief  and  cure. 

BIBLIOGRAPHY. 

Lancet,  London,  1853,  i,  473. 

Coupland,  S.  Tr.  Path.  Soc,  London,  1876  7), 
1877,  xxviii,  179-185. 

Spanton.     Lancet,  London,  1882,  i,  1032. 

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West,  S.  Tr.  Path.  Soc,  London,  1882  3, 
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Wharton,  H.  R.  Med.  News,  Philadelphia, 
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Olivia,  V.     Torino,  1883,  xix,  609,  625,  641,  657. 

Tordeus,  E.  Jourde  med.  chir.  et  pharmacol., 
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Aiken,  A.  Prov.  Med.  Journal,  Leicester, 
1891,  X,  208. 


SUnGER7'  OF  THE  PROSTATE. 


Graetzer,  Georg.  Zur  statistik  der  prostatasar- 
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Marsh,  H.  Tr.  Clin.  Soc,  London,  1S96  7, 
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Burkhart.      1894. 

CANCER    OF    THE    PROSTATE. 
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24 


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SURGERT  OF  THE  PROSTATE. 


25 


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31 


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33 


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SURGER7'  OF  THE  PROSTATE. 


35 


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830. 


36 


SURGE  in'  Oh    7- HE  PROSTATE. 


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Buuistead,  J.  F.  Gonorrheal  Inflammat'on  ot 
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SURGERY  OF  THE  PROSTATE. 


37 


Lefebvre.  Traitement  de  I'hjpertrophie  de  la 
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Uebcr  acute  citrigc  prostatitis.  Ibid  ,  1881, 
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Teflft,  J.  E.  A  Clinical  Lecture  on  Senile 
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38 


SURGERT  Oh    THE  PROSTATE. 


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SURGERT  OF  THE  PROSTATE. 


39 


duzione  del  aatetere  per  gravissime  false  strade 
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4° 


SURGERY  OF  THE  PROSTATE. 


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org,  genito  urin.,  Paris,  1898,  xvi,  400. 

Greene  and  Blanchard.  Some  Observations  on 
the  Prostate,  Journal  Cutan.  and  Genito-Urinary 
Diseases,  New  York,  1899,  xvii,  27  30. 

Christian,  H.  M.  Chronic  Catarrhal  Prosta- 
titis. Journal  Cutan.  and  Genito-Urinary  Dis- 
ea-»s.  New  Y'!rk.  1899   xvii,  18-22. 

Martin,  S.  C  ,  Jr.  Vcute  and  Chronic  Prosta- 
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Urinary  Disease*!,  St.  Louis,  1899,  iii,  27. 

Overall,  G.  W.  Elictrolysis  and  Cataphoric 
Medicatixi) ;  The  Treatment  of  Chronic  Con- 
gested Prostatitis  and  its  Sequels,  Impotency 
and  Spermatorrhea,  Thereby.  Journal  American 
Medical  Association,  1899,  xxxii,  115-119. 

Fabre,  L.  Deformation  du  col  vesical  dans 
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Morris,  W.  E.  Hypertrophied  Prostate,  with 
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iii.  18. 

Heresco  et  Chastenet  de  Gery.  Rentention 
complete  aigue  d'urino  chez  un  prostatique  ca- 
theterisme  difficile  reste  impossible  en  villo  par 
la  production  d'une  fausse  possible  a  I'hospital 
sonde  a  de  eur€.  Ann.  d.  mal.  d.  org.  genito- 
urin.,  Paris,  1899.  xvii,  154-159. 

Fenwick,  E.  II.  Clinical  Notes  upon  the 
Recital,  Contour  and  Consistence  of  a  Thousand 
Prostate  Glands.     British  Medical  Journal,  1899, 

i,  395  399-  , 

Janet,  J.  Ciijeirson  d'accidents  tres  graves 
chezdeuz  prostatiques  par  le  catheterisme.  Ann. 
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160-166. 

Hogan,E.J.  Prostatitis.    Med.  Brief,  St. Louis, 

1899,  xxvii,  359. 

Thumen,  V.  Ueber  prostatitis  gonorrhoica. 
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1900,  870-874. 

Guepin,  A.     Etiologie  generale  des  maladies 


SURGERT  OF  THE  PROSTATE. 


43 


de    la    prostate.      Tribune    med.,    Paris,    iqoo, 
xxxiii,  67  69. 

Carlier.  Retention  d'urine  et  hematurie  chez 
un  prostatique.  Echo  cned.  du  Nord,  Lille, 
1900,  iv,  85-86. 

Desnos,  E.  Des  prostatites  grippales.  Med. 
n  od.,  Paris,  1900,  xi,  241-243. 

Verhoogen,  J.  Le  catheterisme  chez  les  pros- 
tatiques.     Policlin.,  Brux,  1900,  ix,  i  8. 

Hogge.  Traitment  des  prostatites  chroniques 
(discussion).  IV  sess.  assoc.  franc,  d'urol.  Paris 
1899,  proc-verb.,  1900,  322. 

Kennedy,  W.  H.  Prostatitis,  Seminal  Vesi 
culitis  and  Treatment.  Am.  Journal  Dermatol 
and    Genito-Urinary  Diseases,    St.   Louis,   1900 

iv,  I77-I79- 

Cousins,  J.  W.  An  Improved  Prostatic  Ca 
theter.  British  Medical  Journal,  London,  1900 
i,  16,  I  fig. 

Rothschild,  A.  Die  diagnose  und  therapie  der 
gonorrhoischen  prostatitis  ruckblic  und  sammel- 
referat  uber  die  letzen.  funf  jahro.  Deutsche 
med.  Woch.,  1900,  xxvi,  Therap  heil,  38-40. 

Rpdon,  B.  M.  De  los  accidents  eretrales  en 
la  hypertrophia  de  la  prostata  tecinca  del  cathe- 
terismo.  Rev.  val.  de  cien.  med  ,  Valencia,  1900, 
ii,  171-172. 

Legneu.  De  la  hypertrophie  prostatique.  In- 
depend.  med.,  Paris,  1900,  vi,  225-226. 

Castran,  A.  Sur  la  prostatite  chronique.  IV 
sess.  assoc.  franc,  d'urol.,  Paris,  1899,  proc-verb., 
1900  298.312, 

Mincer,  A.  L'hypertrophie  de  la  prostate. 
Gaz.  lek.,  Warszawa,  1900,  xx,  1212  1219. 

Nicoll,  J.  H.  Calculi  from  Three  Cases  of 
Prostatic  Hypertrophy,  in  which  the  Calculus 
Formation  was  Secondary  to  and  Masked  by  the 
Symptoms  of  the  Prostatic  Hypertrophy.  Glas- 
gow Med.  Journal,  1900,  liii,  258  259. 

Delore,  H.  Meat  hypogastrique  avec  survie 
de  il  mois  chez  un  cancereaux  prostatique.  Gaz. 
hebd.    de   med.    et   de   chir.,   Paris,   1800,  xlvii, 

Janet,  Jules.  Phenomenes  des  prostatisme  dans 
la  prostatite  chronique.  IV  sess.  assoc.  franc, 
d'urol.,  Paris,  1899,  proc-verb.,  1900,  312-316. 

M.  (Th.).  Le  Regime  chez  les  prostatiques. 
Hy.  usuelle,  Paris,  vi,  20-22. 

Oberlander,  F.  M.  Ueber  prostata  ver  let  zun- 
gen  durch  unfall.  Centralbl.  f.  d.  krankh.  d. 
harnu.  sex-org.,  Lpz.,  1900,  xi,  9-17,  63  68. 

Herbert,  A.  Sur  la  prostatite  chronique.  Rev. 
med.  de  Normandie,  Rouen,  1900,  i,  172-176. 

Warner,  P.  Management  of  Hypertrophied 
Prostate  Gland.  Am.  Journal  Surgery  and  Gyne- 
cology, St.  Louis,  1900,  xiii,  151-152. 

Lavaux.  Lavages  de  la  vessie  sans  sonde  chez 
les  prostatiques.  Therap.,  contemp.,  Paris,  1900, 
V,  22-23. 

R.  L.  Faut  il  faire  usage  de  la  sonde  dans 
I'hypertrophie  de  la  prostate.  Monit.  therap., 
Paris,  1900,  xxvii,  113-116. 

Kornfeld,  F.  Zur  krankenflege  bei  prostata- 
leiden.  Med. -chir.,  Centralbl.  Wien,  1900,  xxxv, 
117-118,  130.132,  143  145. 

Tiedtnat,  E.  Hypertrophie  de  la  prostate. 
In  Lee.  de  clin.  chir.  faites  d  I'hop.  de  Montpel., 
1900,  361-410. 

Corson,  E.  R.  The  Value  of  Ergot  in  Dis- 
eases of  the  Prostate.  Atlanta  Journal-Record 
of  Medicine,  1900,  ii,  346  249. 

Lose,  P.  Conception  Rctuelle  de  I'hjrpertrophie 


prostatique  du  viellard.  Medic,  martials,  Paris, 
1900,  xiv,  599  6.6. 

Legueu.  De  I'hypertrophie  prostatique.  In- 
depend.  med.,  Paris,  1900,  vi,  233. 

Martigny,  A  De.  Du  traitment  de  la  retention 
incomplete  aigue  chez  le  prostatique.  CUnique, 
Montreal,  1900,  vii,  137  142. 

Miller,  A.  G.  Clinical  Note  on  Residual  Urine 
in  Cases  of  Enlarged  Prostate.  Scottish  Med. 
and  Surg.  Journal,  Edinburgh,  1900,  vii,  101-109. 

Porosz,  M.  Die  acute  entzundung  der  pros- 
tata.    Ungar.    Med.    Presse,   Budap.,    1600,    v, 

457-459-  „     ,      , 

Melchior,  Max.  Beobachtungen  uber  prosta- 
titis Monatsbl.  d.  krankh.  d.  harn.  sex.  apparat., 
Berlin,  1900,  v,  i  11. 

Lohnstein,  H.  Ueber  die  reaction  des  prostata 
secretion  bei  chronischer  prostatitis  und  ihren 
einfluss  auf  die  lebensfahigkeit  der  spermatozoen. 
Deutsche  med.  Woch.,  Leipzig  u.  Berlin,  1900, 
xxvi,  841-844. 

Posner.  Ueber  die  reaction  des  prostata  se- 
crets bei  chronischer  prostatitis  und  ihren  ein- 
fluss suf  die  lebensfahigkeit  der  spermatozoen. 
Deutsche  m<-d.  Woch.,  Leipzig  u.  Berlin,  1900, 
xxvi,  ver  heil,  268. 

Porosz,  M.  Die  therapie  der  acnten  prostii- 
titis.      Heilkunde,  Wien    1900.  iv,  738  761. 

Thomas,  J.  D.  Chronic  Hypertrophy  of  the 
Prostate.  Internat.  Med.  Magazine,  New  York, 
1900,  ix,  330-333. 

Vetere,  G.  La  cura  della  retenzione  nei  pros- 
tatici  specie  in  riguardo  al  careterismo.  Arch, 
internaz.  di  med.  e  chir.,  Napoli,  1900,  xvi, 
267- 283   289  302. 

Guyon,  F.  La  sonde  a  demeure  dans  le  traite- 
ment  de  I'infection  urinaire  des  hemorrhagies 
prostatiques   et   uretrales.     Presse    med.,  Paris, 

1900,  i,  121  214,    5  traces. 

Albarran  et  Halle.  Valeur  et  indications  du 
massage  de  la  prostate.  Gaz.  hebd.  de  med.  et 
chir.,  Paris,  1900,  xivii,  216. 

Frank,  E.  R.  W.  Lesions  blenorrhagiques 
de  la  prostate.  XIII  cong.  internat.  de  med., 
sect,  de  chir.  urin.,  1900,  Paris,  1901,  compt. 
rend.  269-274. 

Blake,  L.  B.  Gonorrheal  Prostatatis.  Boston 
Med.  and  Surg.  Journal,  1901,  cxlv.  137-139- 

Prunas  Tola,  G.  Contributo  alia  cura  della 
disura  senile  da  ipertrofia  prostatica.  Raccogli- 
tore  Med.,  Firli,  1901,  vi,  97-103. 

Freyer,  P.  J.  On  Enlargement  of  the  Prostate. 
Lancet,   London,   1901,   i,   7991.  3  ^gi   149156, 

9  figures. 

Banzet,  S.  Di  choix  des  sondes  et  de  quelques 
diteculties  du  catherisme  chez  les  prostatiques. 
Journal  de  practiciens,  Paris,  1901,  xv,  195- 196. 

Guiteras,  R.  The  Non  Operative  Treatment 
of  Prostatic  Hypertrophy,  with  Special  Refer- 
ence to  Catheter  Life.     New  York  Med.  Journal, 

1901,  Ixxxiii,  389  395. 

Hinder,  H.  V.  C.  Prostatic  Hypertrophy. 
Indian  Med.  Record,  Calcutta,  1901,  xx,  4S5  490. 

Goldberg,  B.  Klinik  diagnostik  therapeutik 
der  prostatitis  bei  und  nach  gonorrhea.  Klin, 
therap.  woch.,  Wien.  1901,  viii,  209-213. 

D'Haenens,  Ed.  Un  cas  de  prostatite  paren- 
chymateuse  chronique  pros  pour  un  cas  de  pveo- 

10  nephrite.     Cliniqiie,   Brux,  T901,  xv,   209-216, 

4  fig- 

Tarnaud,  R.     Etude  sur  les  calculs  de  la  prof 

tate,    Paris,  1901,  127,  p,  17,  fig. 


44 


SURGERr  OF  THE  PROSTATE. 


Moore,  J.  E.  Prostatic  Surgery:  Anatomical 
and  Technical  Reasons  Why.  Annals  of  Sur- 
gery, Philadelphia,  September.  1902,  p   431. 

Thorndike,  P.  Prostatectomy  Casts,  with 
Remarks  on  the  Operation.  Boston  Med.  and 
Surg.  Journal,  August  28,  1902,  p.  233. 

Leiueu.  Prostectomy,  Perineal  Section  and 
Taille  Perineal,  etc.  Annales  des  Mul-tdies  des 
Organes  Genito  Urinaires,  August,  1902.  p  897. 

Andrews,  E.  W.  Infra  pubi>-  Section  for  Pros- 
tectomy. Journal  of  Am.  Med.  Association, 
Chicago,  111.,  October  18,  1902,  p.  955. 

Jacoby,  A.  Bottini's  Operation,  keport  upon. 
Bhrtrag,  etc.,  September  iS,  p.  677.  Deutsche 
medizinische  Woch.,  Berlin. 

Shelmire.  J.  B.  Prostate  Fibres  Encircling 
Vesical  Neck;  Chronic  Contraction.  American 
Medicine,  Philadelphia,  September  20,  1902, 
p.  462. 

Lydston,  G.  F.  Etiology  of  Prostatic  Hyper- 
trophy. Interstate  Med.  Journal,  St.  Louis,  Mo., 
September,  1902.  p.  473. 

Packard,  II.  Prostate  Hypertrophy  and  Bot- 
tini  Operation.  North  American  Journal  of 
Homeopathy,     New     York,     S  'pt'  mber,      1902, 

p.  565. 

Hubbard,  B.  R.  Prostatic  Hypertrophy  ai  d 
Methods  of  Treatment.  California  Med.  [ournal, 
San  Francisco,  September,  1902,  p.  181. 

Bernays,  A.  C.  Prostatic  Hypertrophy,  Path- 
ology and  Etiology  of  and  Suprapubic  Drainage 
as  Slethod  of  Treatment;  Prostatectomy  and 
Momectomy  Recommended.  Medicus,  Fred- 
erick, Md.,  Aueust,  1902,  p.  242. 

Moullin,C.  M.  Present  Position  of  Treatment 
of  Enlargement  of  Prostate.  Edinburgh  Med. 
]ournal,  October,  1902,  p.  317. 

Ricketts,    B.    M.     Surgery   of  Prostate,   Pan- 


creas and  Diaphragm.  Lancet-Clinic,  Cin- 
cinnati, November  i,  1902,  p.  463;  November  8, 
1902,  p.  4S7 ;  November  15,  1902,  p.  513;  Novem- 
ber 22,  IS)02,  p. '528. 

Anderson,  W.  Prostatectomy.  Pacific  Med. 
Journal,  San  Francisco,  Cal.,  November,  1902, 
p.  6,1. 

Cern(  zzi.  Perineal  Prostatectomy  (Per  la 
Storia,  etc  ).  Gazetta  Medica  Lombarda,  Pa- 
lermo, Italy,  October  12,  1902,  p.  401. 

Delbet.  Perineal  Prostatectomie  (Prostatec- 
tomie,  etc.),  Annales  des  Maladies  des  Organes, 
Genito-Urinaires,  October,  1902,  p.  1193. 

Bryson,  J.  P.  Technique  of  Prostatectomy. 
Annals  of  Surgery,  Philadelphia,  November, 
1902,  p.  649. 

Ransohoff,  J.  Prerectal.  Curvilinear  Incision 
for  Prostatic  Abscess.  Annals  of  Surgery,  Phila- 
delphia, November,  1902,  p.  670. 

Freyer.  Reports  ot  cases  ef  Suprapubic  Oper- 
ation for  Prostatic  Hypertrophy.  British  Med. 
Journal,  London,  November  8,  1902. 

Desnos.  Indications  for  Bottini  Operation. 
Presse  Med.,  Paris,  ii,  October  29-November 
8,  190-. 

Kt-yfs,  E.  L.,  Jr.  Symptoms  of  Prostat'C 
Hypertrophy  :  Their  Causes  and  Relief.  Phila- 
delphia Nled.  Journal,  December  6,  1902. 

Rydyeier.  Intracapsular  Resection  for  Pros- 
tatic Hypertrophy.  Centralblatt  f.  Chirurgie, 
Breslau,  October  ir.  p.  1057. 

Schmidt,  L.  E.  Surgery  of  Prostatic  Obstruc- 
tions. Iowa  Med.  Journal,  De&Moines,  Nevem- 
ber,  1902,  p.  579. 

Albarran.  Treatment  of  Prostatic  Hyper- 
trophy. Journal  Am.  Med.  Association,  Decem- 
ber 13,  1902,  p.  1534. 


II. — Surgery  of  the   Pancreas. 


ANATOMY    (17S3-I903). 

The  pancreas  is  the  most  constant  of  all 
f^lands  in  animals,  birds,  reptiles,  and 
most  fish  and  insects. 

A  few  fish  have  glandular  appendages 
which  secrete  a  fluid,  which  answers  the 
purpose  of  true  pancreatic  fluid.  Its  ana- 
tomical arrangement  varies  in  each  class 
of  animal  life.  It  is  larger  and  intermit- 
tent in  carnivora,  and  its  secretion  con- 
stant in  herbivpra. 

The  amount  of  secretion  is  but  little  dur- 
ing fasting,  and  the  amount  proportionate 
with  amount  of  food.  It  is  situated  in  the 
cavity  of  the  duodenum  of  mammals,  most 
birds  and  reptiles. 

The  gland  is  thick,  tongue-shaped,  and 
transverse  to  the  first  lumbar  vertebra,  and 
behind  the  stomach. 

The  right  end  is  larger  and  fills  the  cur- 
vature of  the  duodenum,  to  which  it  is 
adiierent. 

The  tail  end  comes  in  contact  with  the 
spleen. 

In  mammals  the  duct  usually  enters  the 
intestine  within  two  or  three  inches  of  the 
pylorus. 

In  young  dogs  the  pancreas  is  not  con- 
nected with  the  duodenum.  It  is  first  in 
two  parts,  then  it  unites  to  form  one  gland, 
and  one  duct  to  enter  the  intestines. 

In  the  pig  there  is  but  one  duct,  and  it 
opens  into  the  bile-duct.  Its  blood  sup- 
ply in  mammals  is  from  the  superior 
and  inferior  pancreatoduodenal  branches 
of  the  hepatic  and  superior  mesenteric 
arteries. 

The  venus  blood  passes  through  the 
splenic  and  mesenteric  veins.  It  receives 
its  nerve  supply  from  the  solar  plexus. 

Charmiel,  1785,  was  one  of  the  first  to 
report  anatomical  observations  upon  the 
pancreas. 


Stannius,  1848;  Bernard,  1850,  Ver- 
neuil,  185 1  ;  Scherer,  1858,  each  contri- 
buted to  the  comparative  study  of  the 
pancreas. 

Rhode,  iS6^;  Saviotti,  1869;  Pfluger, 
1869;  Langerhaus,  1869,  and  Corse.  1878, 
have  done  much  to  enlighten  our  knowl- 
edge upon  both  physiology  and  anatomy 
of  the  pancreas. 

Pfluger  paid  special  attention  to  the 
nervous  supply,  and  Benaut,  18S0,  to  the 
lympho- glandular  structures  of  vertebrates. 

Hoggan  and  Iloggan,  1881,  did  more 
than  duplicate  the  work  of  Benaut. 

Garrigues,  1881,  publi>hed  his  report  on 
the  anatomy  and  histology  of  a  cyst  of 
the  pancreas. 

Klein,  1882,  contributed  to  the  study  of 
the  lymphatic  system,  and  the  minute  struc- 
ture of  the  pancreas  and  salivary  glands. 

Gibbes,  1884;  Lewaschew,  1885;  Mett, 
1888;  Pavloff,  1888;  and  Asmann,  1888, 
made  a  special  study  of  the  minute  struc- 
ture of  the  pancreas. 

Laguesse,  1889,  made  his  report  upon 
the  development  of  the  pancreas. 

Steinhaus,  1891,  made  his  contribution 
to  the  study  of  parasites  of  the  pancreas 
in  the  amphibians. 

Goppert,  1891,  published  his  work  on 
the  pancreas  of  the  amphibians. 

Petrini,  1892,  made  special  mention  of 
his  research  concerning  the  presence  of 
corpuscles  in  nerve  ganglia^  of  the  pan- 
creas. 

Saint-Remy,  1893,  did  much  for  the 
study  of  the  development  of  the  pancreas. 

Harris,  1895,  made  some  special  obser- 
vations upon  the  comparative  histology  of 
the  pancreas. 

Rogie,  1894,  published  his  notes  on  the 
various  points  concerning  the  anatomy  of 
the  peritoneum  and  morphology  of  the 
pancreas. 


46 


SURGERY  OF  THE  PANCREAS. 


Kroulein,  1895,  made  an  extensive  study 
of  the  topographical  anatomy,  with  special 
reference  to  the  surgery  of  the  pancreas, 

Pugnant,  1896,  contributed  to  the  histo- 
logic study  of  the  pancreas. 

Bachet,  1896,  published  his  research 
work  concerning  the  development  of  the 
pancreas  in  selacians,  reptiles  and  mam- 
mals. 

Francois  Franck,  1896,  developed  a  se- 
ries of  experiments  pertaining  to  the  vaso- 
motor innervation  and  circulation  of  the 
pancreas. 

Popelski,  1S96,  made  a  special  study 
upon  the  nerves  retarding  secretion  of  the 
pancreas. 

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PavloiT,  L.  P.     Ejened  klin.   gaz.,  St.   Peters- 
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Assmann,  E.     Arch.  t.  path,  anat.,  etc.,  Berlin, 

1888,  cxi,  269  280. 

Laguesse,  E.  Compt.  rend.  soc.  de  biol.,  Paris, 

1889,  9s,  i,  341,  343. 

Plainer,  (j.  Arch.  f.  mikr.  anat.,  Bonn,  1889, 
xxxiii,  180-192,  I  pl. 

Steinhaus,  J.  Beitr.  z.  path.  anat.  u.  z.  allg. 
path.,  Jena,  1890,  vii,  367  374. 


Goppert,  E.  Morphol.  jahrb.,  Leipzig,  1891, 
xvii,  100-122. 

Nauwerck,  C.  Beiir.  z.  path.  anat.  u.  z.  allg. 
path.  Jena,  1892,  vii,  29  32. 

Petrini.  Compt.  rend.  soc.  di  biol.,  1892,  9«, 
i^,  275. 

Hamburger,  O.     Anat.  anz  Jena,  1892,  vii,  707. 

Saint-Remy.  G.  Rev.  biol.  du  Nord  de  la 
France,  Lille,  1892  3,  v,  449,  457,  i  pl. 

Schirmer,  Alfred  Max.  Basel,  1893,  82  p., 
a  tab.,  3  pl. 

Hams,  W.  D.  and  G«.w,  W.  J.  Jour.  Physiol., 
Camliridge,  1S93.  xv.  349  360. 

Kotschau,  J.  Centrul.  1.  allg.  path.  u.  anat., 
Jena,  1893,  iv,  454  456. 

Laguesse,  E.  Jour,  de  I'anat.  et  physiol.,  etc., 
Paris,  1894,  XXX,  591,  731. 

Morat.  Gaz.  de  hop.  de  Toulouse,  1894,  viii, 
217-  19. 

Laguesse,  E  Compt.  rend.  soc.  biol.,  Paris, 
1894,  ^OS'  ^'  ^^7  669. 

Rogie,  C.  E.  Jour.  d.  sc.  med.  de  Lille,  1894, 
ii,  169,  209,  233,  257,  .81,5  pl. 

Tschaussow,   M.     Anat.    anz.    Jena,    1895,   ^'' 

342 -355 • 

Kroulein.  Beitr.  z.  klin.  chir..  Tubing.,  1895, 
xiv,  663  696,  5  pl. 

Kasahara,  M.  Arch.  f.  path.  Anat.,  etc.,  Ber- 
lin, 1S96,  cxliii.  III     42. 

Pugnat,  C.  A.  Coinpt.  rend.  soc.  de  biol., 
Paris,  1896,  los,  iii,  1017. 

Brachet,  A.  Jour,  de  I'anat.  at  physiol.,  etc., 
Paris,  1896,  xxxii    620  696,  3  jil. 

Francois-Franck  et  Hallien.  Compt.  rend, 
soc.  de  biol  ,  Paris,  1S96,  los,  iii,  561  563. 

Popelski.  Trudi  { )l)sli.  russk.  vrach,St.  Peters- 
burgh,  1896-7,  55  66. 

Francois-l'rauck  et  llallion.  Arch,  de  Ph}-- 
siol.  norm,  et  path.,  Paris,  1897,  5s,  ix,  661  676. 

Pugnat,  C.  A.  J^'ur.  de  I'anat.  micr.,  Paris, 
1897,  i,  137-152,  I  pl- 

Mayr,  J.  Anat.  hefte  VViesb.,  1897,  viii, 
75-151,  8  pl. 

ABNORMALITIES    (1S42-I903). 

Abnormalities  of  the  pancreas  are  quite 
frequent.  There  may  be  one  or  more  ac- 
cessory lobes.  They  may  or  may  not  be 
connected  with  the  pancreas  proper. 

The  pancreatic  duct  in  man  may  have 
several  bifurcations,  each  entering  the 
common  duct  or  the  intestinal  tract  at 
different  points. 

The  position  of  the  pancreas  may  vary. 
Its  normal  relation  to  other  organs  may 
also  vary. 

The  pancreas  may  consist  of  one  or  more 
lobes,  each  having  its  own  duct  to  enter 
the  pancreatic  duct  or  the  duodenum. 

Le  Blanc,  1842,  wrote  upon  the  analo- 
gies and  the  differences  found  in  the  pan- 
creas and  the  salivary  glands. 

Bodinier,  1843,  described  the  pancreatic 
canal,  together  with  a  unique  orifice  of 
the  common  bile  duct. 

Lynah,  1852,  reports  a  case  of  cancer  of 


SURGERT  OF  THE  PANCREAS. 


47 


the  liver,  absence  of  the  pancreas,  and 
almost  complete  occlusion  of  duodenum. 

Hoppe,  1S56,  describes  an  abnormal 
pancreas. 

Berard,  1856,  mentions  accessory  pan- 
creatic glands,  which  were  capable  of 
doing  the  work  of  the  normal  pancreas. 

See,  1838,  and  Klob,  1859,  each  report 
anomalies  of  the  pancreas,  while  Mont- 
gomery, i860,  and  Wagner,  1863,  describe 
cases  of  accessory  pancreatic  glands. 

Dijerine,  1S76,  reports  a  case  of  sclero- 
sis of  tlie  pancreas,  and  obliteration  of  the 
canal  choledochus,  with  icterus. 

Fry,  1881,  records  a  case  of  dislocation 
and  transformation  of  the  pancreas. 

Estes,  1882,  mentions  one  of  displace- 
ment of  the  pancreas  and  spleen,  with 
sloughing  of  both  organs,  and  gangrene 
of  intestines. 

Symington,  1884;  Bimar,  18S7;  Apol- 
lioni,  1887;  Genersich,  1890;  Bocardi, 
1891  ;  Neve,  1893;  Charpy,  1898;  Helly, 
1899;  Letulle,  1900;  Nichols,  1900;  Gi- 
ordano, 1900;  and  Glinski,  1901,  each 
record  anomalous  and  accessory  pancre- 
atic glands. 

Zenker  reports  six  cases  in  which  he 
found  accessory  pancreatic  lobes. 

Klob  found  no  excretory  duct  in  his 
specimen.  lie  thinks  that  accessory  lobes 
are  due  to  embryonic  tissue. 

There  has  been  no  malignant  disease  of 
such  lobes  found  on  record. 

BIBLIOGRAPHY. 

Le  Blanc  de  Varennes,  M.  L.     Paris.  1842. 

Bodinier.  Bull,  soc,  anat.,  Paris,  1843,  xviii, 
262. 

Lynah,  A..  M.  Charleston  Med.  Journal,  1852, 
vii,  325  328. 

Hoppe,  F.  Arch.  f.  path,  anat.,  etc.,  Berlin, 
1856,  xi,  96  98. 

Berard,  Quand.  Bull.  Acad,  de  med.,  Paris, 
1856  7,  xxii,  iioo  1107. 

See,  M.  Comp.  rend.  Soc.  debiol.,  1857,  Paris, 
185,8,  2  s,  iv,  I. 

Klob,  ].  Ztch.  d.  k.  k.  gesellch.  d.  aerzte  zu 
Wien,  1859,  XV,  732. 

Montgomery,  E.  Tr.  Path.  Soc,  London, 
i86o-t,  xii,  130. 

Wagner,  E.    Arch.  d.  heilk.,  Lpg  ,  1862, 111,283. 

Ecker,  A.  Bildungsfehler  des  pancreas  und 
des  herzens.  Ztschr.  f.  rat.  med  ,  Leipsig.  186', 
3  R,  xiv,  354  356,  I  pi.  SuUe  funzion  del  pan- 
creas e  della  milza.  Imparziale  Firenze,  1865,  v, 
115  117. 

Dejerine,  J.  Bull.  soc.  d.  anat.  Paris,  1876, 
li,  165-167. 

Fry,  J.  T.  Texas  Med.  and  Surg.  Record, 
Galveston,  1881,  i,  3-'5  329. 

Estes,  W.  L.  Med.  News,  Philadelphia,  1882, 
xli,  119  121. 


Symington,  J.  Jour.  Anat.  and  Physiol.,  Lon- 
don, 18S4  85,  xix,  292. 

Bimar.  Gaz.  hebd.  d.  sc.  med.  de  Montpel., 
1887,  ix,  232-234. 

ApoUioni,  C.  Gaz.  d.  osp  ,  Milano,  1S87,  viii, 
196 

Van  Gieson.  Accessory  Pancreas  in  the  Wall 
of  the  Duodenum  Simulating  a  Tumor.  Proc. 
N.  Y.  Med.  Soc.  (1888),  1889,93. 

Genersich,  A.  Verhandl.  d.  X  Internat.  med. 
cong.,  i860,  Berlin,  1891,  ii,  3  abth.,  140144. 

Bocardi,  G.  Arch.  ital.  de  biol.,  Jurin,  1891, 
2,  xvi.  50-58. 

Neve,  E.F.  Indian  Med.  Record,  Calcutta, 
1892,  iii,  71. 

Charpy,  A.  Jour.  anat.  et  physiol.,  etc.,  Paris, 
189S,  xxxiv,  720-734. 

Helly,  K.  K.   Wien.  klin.  Woch  ,  1899,  xii,  207. 

Letulle,  M.  Comp.  rend.  soc.  biol.,  Paris, 
1900,  Hi,  233  235. 

Nicholls,  A.  G.  Montreal  Med.  Journal,  1900, 
xxix,  903  907,  I  fig. 

Giordano,  D.  Clin,  chir.,  Milano,  1900,  viii, 
242-51. 

Glinski,  L.  K.  Przegllek.,  Krakow,  1901,  xl, 
6^-31.  44  47- 

PHYSIOLOGY    (1667-I9O3). 

The  physiology  of  the  pancreas  has 
occupied  the  minds  of  many  observers  for 
several  hundred  years;  as  early  as  1667  it 
was  believed  to  be  influential  in  producing 
sugar  in  the  urine. 

The  pancreatic  cells  become  much  larger 
during  digestion,  and  are  greatly  influ- 
enced by  the  different  foods  taken  into 
the  stomach.  It  is  supposed  to  have  some 
specific  action  upon  the  ferments.  Its 
of^ce  is  not  well  understood,  and  its  com- 
plete extirpation  results  in  immediate 
death. 

Swalve,  1667,  believed  that  the  pancreas 
was  influential  in  producing  sugar  in  the 
urine. 

Saumarez,  1806,  wrote  upon  the  func- 
tions of  the  pancreas. 

Rush,  1806,  made  an  inquiry  into  the 
functions  of  the  pancreiis,  spleen,  liver, 
and  thyroid  gland. 

Sewall,  1813,  in  an  inaugural  address 
gave  quite  a  dissertation  on  the  functions 
and  diseases  of  the  pancreas. 

Bouchardat  and  Sandras,  1845,  wrote 
on  the  functions  of  the  pancreas  and  its 
influence  upon  digestion. 

Fanconneau-Dufrescue,  1S47,  delivered 
an  address  upon  the  subject  of  pancreat- 
ologie. 

Moyse,  1S53,  wrote  a  critical  history 
on  the  functions  and  maladies  of  the  pan- 
creas. 

Lussana,  1S52,  wrote  upon  the  chemical 
physiology  of  the  pancreas. 


48 


SURGERV  OF  THE  PANCREAS. 


Virchow,  1853,  also  wrote  upon  the 
same  subject. 

Bernard,  1856,  gave  a  memoir  on  the 
pancreasi,  and  the  particular  plienomena 
it  produced  in  digestion. 

Corvisart,  18^7,  wrote  a  similar  article. 

Embleton,  1874,  wrote  a  paper  on  the 
symmetry  of  the  pancreas  and  spleen. 
"Do  the  shoulder  tips  pain,  and  other 
sympathetic  pains  occur  in  disease  of  these 
twomembersof  the  pneumogastric  series?" 

Fossion,  1S77,  gave  notes  on  the  func- 
tions of  the  pancreas. 

Langley  and  Sewall,  1879,  wrote  on  the 
changes  in  pepsin-forming  glands  during 
secretion. 

Kurschinski,  1888,  reports  the  effects  of 
some  digestive  and  pharmaceutical  pre- 
parations for  promotion  of  secretion  of 
pancreatic  juice. 

Pilliet,  1889,  wrote  on  the  transforma- 
tion of  fat  by  the  pancreas, 

Zawadzti,  1890,  considers  the  chemical 
composition  of  the  pancreatic  juice  of  man. 

Gley,  1891 ,  makes  his  preliminary  report 
on  alimentary  glycosuria,  and  the  relation 
of  the  pancreas  to   it. 

Abelous,  1891,  speaks  on  the  action  of 
antiseptics  on  the  pancreatic  ferments, 
and  on  giving  doses  of  them  as  antizy- 
motics. 

Chauveau  et  Kaufmann,  1S93,  speak 
of  the  pancreas,  and  the  regulating  the 
function  of  glycosuria. 

Dastre,  1893,  writes  upon  his  observa- 
tions on  pancreatic  digestion  in  a  note  to 
Herzon. 

Ver  Eecke,  1893,  speaks  of  the  modifi- 
cation in  the  pancreatic  cells  during  active 
secretion. 

Kassillief,  1893,  contributes  a  study  of 
the  physiology  and  pharmacology  of  the 
pancreas. 

Gottlieb,  1894,  contributed  an  article 
upon  the  same  subject. 

Harris  and  Grace-Calvert,  189:1.,  wrote 
upon  the  human  pancreatic  ferments  in 
disease. 

Jablousky,  1895, 'contributed  a  study  on 
the  physiology  and  pharmacology  of  the 
pancreas,  and  a  comment  of  panolacte  on 
the  pancreas. 

Yablonski,  1895,  mentions  the  activity 
of  the  pancreas  under  the  influence  of  a 
milk  and  bread  rcgiuic. 

Gutschy,  1898,  speaks  of  the  influence 
of  the  spleen  on  the  pancreatic  juice. 

Hedon   and  \  ille  made  experiments  to 


determine  the  effects  of  digestion  of  fats 
when  the  pancreatic  fluid  is  removed  by 
fistula  or  the  extirpation  of  the  pancreas. 

Schirokokh,  1900,  studied  the  effects  of 
local  irritation  with  the  common  stimu- 
lants on  the  pancreatic  secretion  under 
normal  conditions. 

niBLIOCRAPHY. 

Swalve,  B.     Amstelodami,  1667. 

GrieslaiiP,  J.  G.  De  repeiUina  sua  morte  ex 
panceate  sjiliacelato  et  ohiter  de  potentia  imaei- 
nationis.  ISIisc.  ecad.  nat.  curios,  1672;  Leipzig, 
Francof,  i6.Sr,  iii,  65. 

Saumarez,  R.  Med.  and  Phjs.  Journal,  Lon- 
don, 1806,  xvi,  2S9  300. 

Rush,  ii.  Med.  and  Pliys.  Journal,  London, 
1S06,  xvi,  193  208. 

llildebrandt,  F.  Abhandl.  d.  Phys.  med.  soc. 
zu  Erlang.,  1810,  i,  251-267. 

Sewall,  T.  New  England  Journal  Medicine 
and  Science,  Boston,  1813,  ii,  20-25. 

Tiedemann,  F.  Ueber  die  verschiedenheiten 
des  ausfuhrungsgangs  der  bauchspeicheldruse  bei 
dcni  menschen  und  der  sauge  thieren  1).  Arch, 
f.  d.  physiol.,  Halle.  1818,  iv,  405-411. 

Bpucchardat  and  Sandras.  Conipt.  rend.  acad. 
d.  sc,  Paris,  1845,  xx,  1085  1091. 

P^auconneau  -  Duffescue.  Union  med.,  Paris, 
1847,  i,  2,  6,33. 

Bernard.  Claude,  1848. 

Moyse,  D.     Paris.  1S52. 

Lussana,  F.     Gazz.  med.   Ital.   lomb.,  Milano, 

1852,  iii,  297,  305,  313. 

Virchow.    R.     Arch.    f.    path,    anat.,     Berlin, 

1853,  vii,  580. 

Weinmann,  A.  Ztschr.  f.  nat.  med.,  Heidelb., 
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Alessandrini,  A.     Bononiae,  1855. 

Bernard,  C.     Paris,  1856. 

Corvisart,  L.  Azotes  Gaz.  hebd.  de  med., 
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Moore,  W.  J.  Tr.  Med.  and  Phys  Soc,  Bom- 
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Paris,  1895,  io^>  •'»  847-850. 

Mouret,  J-     Jour,  de  I'anat.  et  phjsiol..  Paris, 

1895,  xxxi,  2.'i  236,  I  pl. 

Carvallo  et  Pachon.  Pouvior.  Digestif  du 
pancreas  dens  I'etat  do  jeune  chez  les  animaux 
normaux  et  derates.  In  Richet  C.  Physiol.  I  rav. 
du  lah,  Paris,  1895.  iii,  426  444. 

Kotlar,  E.  Ueber  den  eiiitluss  dts  pankreas 
auf  das  wachstum  eingcr  palholencn  spaltpilze. 
Centrbl.  f.  bakteriol.  u  paraseitenk.,  Jt-na,  1895, 
XV  ii,  145-168. 

Albini,  (J.  Riforma  mcd.  Napoli,  1895,  xi, 
pt    I,  220-230. 

Bourqueiot  et  Gley.  Compt.  rend,  de  soc. 
biol.,  Paris,  1895,  los,  ii,  238  240. 

Yablonski,  I.  Bach.  biol.  nauk.,  St.  Petersb., 
1895-6,  iv,  377-390- 

Floresco.  N.  Compt.  rend,  de  soc.  biol.,  Pans, 

1896,  los,  iii.  77. 

Savelyeff,  N.  A.  and  I.  I.  Stotski.  Med.  obozr. 
Mosk.,  1897,  xlvii,  961.-976. 

Baldi,  D.  Arch.  It.il.  de  biol.,  Turin,  1897, 
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Ixx,  329-345. 

Yung,  E.  Compt.  rend.  acad.  d  sc,  Pans, 
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Opie.  Jour,  of  Exper.  Medicine,  1901,  v.  p.  398. 

Opie.     Loc.  cit.,  p.  399. 

Opie.  The  Relation  of  Diabetes  Mellitus  to 
Lesions  of  the  Pancreas.  Jour,  of  Exjier.  Medi- 
cine. 1901,  v,  d.  5?9. 

Flexner.  Johns  Hopkins  Hospital  Reports,  ix; 
also  Univer.  of  I'enn.  Medical  Bulletin,  August, 
1901. 

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1901. 

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p.  146,  1901. 

Chittenden.  R.  H.  Physiology  of  the  Pan- 
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vol.  81,  No.  6,  p.  241-246. 

Von  Mering  and  Minkowski.  Di.ni>etes  Mel- 
litus nach  Pankieas  c.xiii  pation.  Archiv.  f.  i  xp. 
path.  u.  pharm.,  Bd.  26,  p.  371. 


50 


SURGERr  OF  THE  PAXCREAS. 


Minkowski.  Untersuchungen  uber  den  Dia- 
betes Mellitus  nach  Extirpation  des  Pankreas. 
Archiv.  f.  exper.  path.  u.  pharm.  Bd.  31.  p.  85. 

Minkowski.  Untersucluingen  uber  den  Dia- 
betes Mellitus  nach  Extirpatiou  des  Pankreas. 
Archiv.  f.  exper.  path.  u.  pharm.,  Bd.  31,  p.  105. 

EXPERIMENTAL    (1643-I9O3). 

Wirsung,  J.G.,  1645,  anatomist,  Padua, 
discovered  the  pancreatic  duct  and  the 
fluid  which  flows  through  it. 

De  Graaf,  a  pupil  of  Sylvius,  of  Leyden, 
1664,  made  a  pancreatic  fistula,  and  col- 
lected pancreatic  fluid.  Using  the  quill 
of  a  wild  duck  as  a  cannula,  he  opened 
the  abdomen  of  a  dog  and  introduced  it 
into  the  duct  of  Wirsung,  and  collected 
one  ounce  of  pancreatic  fluid  in  about 
seven   hours. 

Brunner,  1662,  holding  a  chair  of  medi- 
cine at  Heidelberg,  published  the  results 
of  his  experiments  upon  extirpation  of  the 
pancreas  from  dogs.  He  states  that  the 
animal  recovered  from  the  operation  with- 
out any  noticeable  after-effects. 

As  early  as  1685  experiments  with  refer- 
ence to  its  arterial  supply  and  its  secretion 
were  made.  Experiments  have  been  more 
numerous  of  recent  years,  and  have  been 
rather  general  in  their  application,  both 
as  to  the  functions  and  the  effects  of  its 
extirpation. 

Brunner,  1683,  conducted  ex{)eriinents 
with  reference  to  the  arterial  supply  and 
secretion  of  the  pancreas,  and  in  1688 
confirmed  his  first  observations. 

Epallanzani,  1785,  made  many  observa- 
tions upon  pancreatic  digestion. 

King,  1827,  and  Bicourt,  1830,  each  ex- 
perimented extensively  upon  the  functions 
of  the  pancreas,  the  latter  especially  being 
interested  in  the  secondary  organic  changes. 

Beaumont,  1830,  experimented  upon 
Alexis  St.  Martin,  who  had  received  a 
gun-shot  wound  in  the  stomach  resulting 
in  an  external  fistula. 

Bouchardat  and  Sandras,  1845,  estab- 
lished amylolytic  power. 

Corviscart,  1857,  proved  the  proteolytic 
power  of  the  pancreatic  secretion. 

Turner,  i860,  employed  transparent  in- 
jections in  the  examination  of  the  minute 
structures  of  the  human  pancreas. 

Diakonoft',  1865,  experimented  with 
albuminous  matter  digested  in  pancreatic 
juice. 

Arnozau  and  Vaillard,  1880,  ligated  the 
pancreatic  duct  that  they  might  observe 
the  alterations  in  the  organic  tissues. 


Nussbaum,  1884,  conducted  research 
work  to  determine  the  action  of  different 
poisons  on  the  pancreas. 

Di  Mattel,  1885,  irritated  the  pancreas 
to  determine  the  effect  upon  its  secretion  ; 
and  Verardini,  1888,  did  so  on  animals, 
that  he  might  study  the  elimination  of 
fat. 

De  Dominicus,  1889,  experimented  upon 
the  lower  animals  that  he  might  observe 
the  effects  of  the  extirpation  of  the  pan- 
creas on  diabetes. 

Inoko,  1892,  of  Japan,  ligated  the  pan- 
creatic duct  to  study  the  results. 

Hedin,  1891,  contributed  much  to  the 
experimental  study  of  the  pancreas. 

Thiroloix,  1892,  experimented  upon  the 
external  and  internal  secretion  of  the  pan- 
creas, with  special  reference  to  its  physi- 
ology and  diabetes. 

Schabad,  1892,  experimented  upon  the 
same  subjects. 

Thiroloix,  1892,  experimented  to  observe 
the  effects  of  suppressing  the  flow  of  the 
pancreatic  fluid  into  the  duodenum. 

Harris  and  Gow,  1892,  experimented 
upon  different  animals  to  determine  the 
action  of  pancreatic  ferments. 

Gley,  1892,  destroyed  the  pancreas  to 
study  the  effects  of  the  absence  of  its 
seTetion  upr>n  digestion. 

Cavaz-zani,  1893,  contributed  an  exten- 
sive study  on  the  consecutive  alterations 
due  to  extirp  ition  of  the  pancreas. 

Harley,  1894,  noticed  the  absorption 
and  metabo'ism  in  obstruction  of  the  pan- 
creatic duct. 

Dolinsky,  1894,  stimulated  the  pancre- 
atic secretion  with  the  local  application 
of  acid. 

Mouret,  1895,  mentions  certain  pancre- 
atic lesions  resulting  from  injections  into 
and  ligating  the  canal  of  Wirsung. 

Biondi,  1896,  contributed  a  clinical  and 
experimental  study  of  surgery  of  the  pan- 
creas. 

Korte,  1896,  experimented  concerning 
fat  necrosis  and  the  possibilities  of  its 
relief  by  surgical  means. 

Valter,i896,  writes  concerning  the  work 
of  the  pancreas  in  the  introduction  of 
meat,  bread,  milk  and  acids. 

Katx  and  Winkler,  1898,  made  obser- 
vations on  the  experimental  study  of  fat 
necrosis. 

Hildebrand,  1S98,  included  the  study 
of  pancreatitis  and  hemorrhage  in  his 
experimental  work  on  fat  necrosis. 


SURGERT  OF  THE  PANCREAS. 


51 


Williams,  1S98,  confined  his  experi- 
mental study  of  fat  necrosis  alone. 

Gipolina,  1S9S,  experimented  concern- 
ing the  regeneration  of  the  pancreatic 
tissue. 

Flexner,  1900,  experimented  on  pan- 
creatitis. 

The  injection  of  paraffine  has  been  made 
into  the  canal  of  Wirsung  to  determine  the 
effects  of  its  obstruction. 

ISIeissner,  Kuhne,  Ileidenhain,  Langley, 
Korsel  and  Pawlow  have  added  much  to 
our  knowledge  of  the  physiology  of  the 
pancreas. 

Eperiments  have  shown  that  pieces  of 
pancreas  transplanted  under  the  skin  will 
functionate  and  preserve  life  after  com- 
plete excision  of  the  pancreas.  But  when 
the  grafted  portion  is  completely  excised 
(with  the  absence  of  the  original  pan- 
creas) glycosuria  will  again  rapidly  appear. 

Alering  and  ISlinkovvi^ki  showed  that 
removal  of  the  pancreas  caused  glycosuria 
(diabetes) . 


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Percival,  E.  Two  Cases  of  Intlamniation  and 
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Warren,  J.  C.  A  Case  where  the  Pancreas 
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Ht)lscher,  G.  P.  Ileus  in  lulge  vi>n  h\pertro- 
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Freckles,  L.  Pancreatitis  chronica  mit  begin- 
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Lolller.  Induratio  pancreatis  Tinct.  jodis. 
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du  canal  choledoque  par  la  tete  de  cet  organe. 
Compt.  rend.  soc.  biol  ,  Paris,  1849-1850,1,65 

Stille.  Enlargement  and  Induration  of  the 
Pancreas.   Tr.  Path.  Soc,  Philadelphia,  1857-60, 

i.  34- 

Castelain.  Hypertrophie  du  pancreas.  Bull, 
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Rigal.  Hypertrophie  du  pancreas  avant  pro- 
duit  une  compression  de  la  veine-cave  inferieure 
et  des  canaux  biliares  degeneration  graisseuse 
du  foie  des  reins  et  du  pancreas  ictere  grave 
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1866-70,  2s,  ii,  310.319.  Sur  la  formation  des 
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Barton,  J.  M.  Tumor  of  the  Pancreas  and  of 
the  Pylorus;  Calcareous  Deposit  in  Pulmonary 
Aortic  and  Mitral  Valves.  Tr.  Path.  Soc,  Phil- 
adelphia, (1871-3),  1874,  i"^''  7^- 

Pepper,  W.  Tumor  of  the  Head  of  the  Pan- 
creas. Proc.  Path.  Soc,  Philadelphia,  1871,  ns. 
Ixi,  \tf)  161. 

Sattervvaite,  T.  E.  Bloody  Tumor  of  the  Pan- 
creas.    New  York  Med.  Journal,  1875,  xxii,  170. 

Ellis.  Obstruction  of  the  Common  Duct  De- 
pending upon  Hardening  of  the  End  of  the  Pan- 
creas. Boston  Med.  and  Surg.  Journal,  1877, 
xcvii,  531. 

Hesse.  Tumor  of  Pancreas.  Proc.  Med.  Soc. 
County  Kings,  Brooklyn,  1879-80,  iv,  94. 

Baudch.  J.  Ueber  angiome  myxomatosum  des 
pancreas  (cylindroma)  ein  beitrac  zur  casuislik 
der  pankreas  cysten.     Freiberg,  1885. 

Bonnamy,  J.  Etude  clinique  sur  les  tumeurs 
du  pancreas.     Paris,  1879. 

Morache.  Induration  hypertrophique  du  pan- 
creas dans  un  cas  de  tuberculosis  generalisee. 
Jour,  de  med.  de  Bordeuax,  1881-2,  xi,  154. 


SURGER2'  OF  THE  PAXCREAS. 


53 


Bruen,  E.  T.  Small  Tumor  of  the  Head  of 
the  Pancreas.  Tr.  Path.  Soc,  Philadelphia, 
(881-2;    1884,  xi,  45. 

Kuyshinski,  P.  D.  Tumor  of  Head  of  the 
Pancreas.  Ejended  klin.  gaz.,  St.  Petersb.,  1887, 
vii,   183  189. 

Segre.  R.  Studio  clinico  sui  tumori  del  pan- 
creas. Ann.  univ.  di  med.  e  chir.,  Milano,  1888, 
cclxxxiii,  3  62. 

Councilman.  Primary  Tumor  of  the  Pancreas. 
Johns  Hopkins  Hosp.  Bull.,  Baltimore,  1886-90, 

I,  51- 

Cesaris-Demel,  A.  Di  un  adenoma  acinose 
del  pancreas  con  pancreatic  indurative  d'origine 
sifilitica.  Gior.  d.  r.  Acad.  med.  di  Torino,  1895, 
Iviii,  199  201. 

Bell.  Fibroid  Pancreas.  Montreal  Med.  Jour- 
nal. 1895-6,  xxiv,  225. 

Flexner,  S.  Nodular  Tumors  of  the  Pancreas. 
Maryland  Med  Journal,  Baltimore,  1899,  '^'i)  'o7- 

Villar,  V.  Diagnostic  et  traitement  tumeurs 
du  pancreas.  XHI  Cong,  internat.  de  med.,  sect, 
de  chir.  gen.,  1900,  Paris,  1901,  compt.  rend, 
2r4  216. 

Barling,  G.  Remarks  on  Chronic  Enlarge- 
ment of  the  Pancreas  in  Association  With  or 
Producing  Attacks  Simulating  Biliary  Colic. 
British  Med.  Journal,  London,  1900,  ii,  1766  1768, 
2  fig. 

Kucera,  P.  L.  Emphyseme  des  organes  et 
angiopancreatite  suppurative.  Gaz.  lek.  Wars- 
zawa,  1900,  XX,  241  247,  280-285,  305-310. 

Bozzolo,  C.  Tumore  del  pancreas  e  del  colon 
con  diabete  morte  per  enterorragia.  Clin,  med., 
Pisa,  1921,  vii,  145-148,  155. 

FAT   NECROSIS. 

Taylor.  Cirrhosis  of  Liver;  Inflammation  of 
its  Peritoneal  Coat;  Disease  of  the  Pancreas; 
Softening,  with  Thinness  of  the  Mucous  Coat  of 
the  Stomach;  Enlargement  of  the  Spleen.  Lon- 
don Lancet,  1841-2,  i,  223-227. 

Lowenhardt.  Woch.  f.  d.  ges.  heilk.,  Berlin, 
1845,  638-640. 

Verga,  A.  Gaz.  med.  Ital.  lomb.,  Milano,  1850, 
3s,  i,  200-202. 

Clark,  A.  Case  of  Disease  of  the  Pancreas 
and  Liver,  Accompanied  by  Fatty  Discharge 
from  the  Bowels.  Lancet,  London,  1851,  ii,  152. 
British  and  Foreign  Med.  Chir.  Rev.,  London, 
1853,  ^'')  154-166. 

Herbst,  G.  Die  unterbindung  des  wirsung 
'schen  ganges  an  kinnichen  mit  rucksichtauf  die 
Bernard'sche  ansich  uber  den  zweck  des  pankre- 
atischen  saften  saftes.  Ztschr.  f.  rat.  med., 
Heidell).,  1855,  nF,  ili,  389-391. 

Jones,  11.  11.  Tr.  Path.  Soc,  London,  1854-5, 
vi,  223. 

Jones,  C.  II.  Med. -Chir.  Tr.,  London,  1855, 
xxxviii,  195  217,  2  pi. 

Caley.  Tr.  Path.  Soc  ,  London,  1872-3,  xxiv, 
121. 

Lepine  and  Cornil.  Compt.  rend.  soc.  blol., 
1874,  Paris,  1875,  6s,  i,  372-374- 

Albertoni,  P.     Firenze,  1878,  xlii,  16-20. 

Litten,  M.  Chaite  Annallen,  1878.  Berlin, 
1880,  V,  181-193.  Riv.  Ital.  di  terap.  ed  ig.,  Pla- 
cenza,  1882,  ii,  3,  33,  65,  97,  137,  177,  241,  280. 

Chambers.  Maryland  Med.  Journal,  Balti- 
more, 1883-4,  ^i  656. 

Van  Gieson,  J.  Med.  Record,  New  York, 
1888,  xxxiii,  477. 


Konig,  William.  Ein  nach  blutting  und  fett 
nekrose,  1889,  Kiel. 

Van  Gieson,  I.  Proc.  New  York  Path.  Soc 
(1888),  1889.  47. 

Podbielski  A.  I.  Vrash,,  St.  Petersb.,  1889 
X,  590-595- 

Loomis,  H.  P.  Med.  Record,  New  York 
1890,  cxxii,  105. 

RoUestpn.  British  Med.  Journal,  London 
1892,  ii,  894. 

Balser,  W.  Verhandl.  d.  cong.  f.  innere  med. 
Wiesb.,  1892,  xi,  450-461. 

Ponfick.  Jahrsb.  d.  schles,  gessch.,  f.  vaterl 
cult.,  1893,  Bresl.,  1804,  Ixxi,  i  abth.,  med.  sec 
tion  35. 

Stockton  and  Williams.  Am.  Jour.  Medical 
Sciences,  Philadelphia,  1895,  ns.  ex,  251  259. 

Le  Cf'unt,  E  E.  Jour.  Am.  Med.  Assn.,  1896, 
xxvi,  581. 

William?,  W.  C.  Chicago  Med.  Record,  1896, 
X,  37-42. 

Strube,  G.  Charite  Ann.,  Berlin,  1897,  xxii, 
222  228.  Riforma  med.,  Pelermo,  1900,  i, 
103-105. 

Libikk,  P.  L.  Bolnitsch.  gaz.  Botkina,  St. 
Petersb.,  1900,  xi,  48-54. 

Opie,  E.  L.  The  Relation  of  Cholelithiasis 
to  Disease  of  the  Pancreas  and  to  Fat  Necrosis. 
Am.  Jour.  Med.  Sciences,  Philadelphia,  1901, 
cxxi,  27-43. 

Schmidt,  M.  B.  Muench.  med.  woch.,  1900, 
xlvii,  640  642. 

Wagner,  Hermann.  Inang.  Diss  ,  Heidelberg, 
1900,  Juli  u.  August. 

Brentano,  A.  Arch.  f.  klin.  chir.,  Berlin,  1900, 
Ixii,  640,  642. 

Lederer,  Franz.  Inaug.  Diss.,  Munchen,  1900, 
Aug.  u  Sept. 

Brentano.  Verhandl.  d.  deutsch.  desellsch.  f. 
chir.,  Berlin,  1900,  xxix,  Th    2,  390  418. 

Miyo,  W.  ].     On  Fat  Necrosis,  1902. 

Blumer,  G.  Some  Aspects  of  the  Pathology 
of  the  Pancreas  of  Recent  Investigation.  Med. 
News,  New  York,  August  9,  1902,  Vol.  81,  No.  6, 
p.  246-248. 

LYMPHOMA. 

This  form  of  new  growth  in  the  pan- 
creas is  exceedingly  rare.  Its  pathology 
is  therefore  limited,  and  little  known. 

The  pancreatic  tissue  sulYers  from  pres- 
sure, and  may  therefore  become  cystic, 
especially  if  the  duct  is  involved. 

Such  a  case  was  reported  by  Lepine  ^nd 
Cornil  [Gaz.  Med.  dc  Paris,  1S74,  4  s., 
iii,  624). 


Panarolus  wrote  upon  this  subject  (re- 
porting such  a  case  involving  the  pan- 
creas), in  his  "  latrologismorum  Romae," 
1652,  51.  He  was  rather  explicit  in  his 
description  of  "  lapidosum,"  and  there  can 
be  but  little,  if  any,  doubt  as  to  the  cor- 
rectness of  his  statements  concerning 
him. 


54 


SURGER7-  OF  THE  PANCREAS. 


ATROPHY. 

The  absence  of  reported  cases,  other 
than  the  two  herein  mentioned,  would 
indicate  that  simple  atrophy  of  the  pan- 
creas is  one  of  its  rarest  conditions. 

Its  secretion  is  lessened  in  anjount  so 
that  it  is  difficult  to  determine  what  amount 
of  pancreatic  fluid  is  necessary  to  main- 
tain life. 

Gairdner,  1850,  reported  a  case  of 
atrophied  pancreas,  giving  quite  a  lengthy 
discussion  of  it,  the  history  of  the  patient, 
and  subsequent  results. 

Yeo,  1874,  records  a  case  of  atrophy  of 
the  pancreas  associated  by  hydro- pneumo- 
thorax. The  latter  condition  was  prob- 
ably coincidental. 

LUMBRICOIDES. 

These  parasites  have  been  known  to 
pass  through  the  duct  into  the  pancreas, 
causing  its  obstruction,  and  subsequent 
trouble,  or  die,  to  cause  infection,  abscess 
or  cystic  degeneration. 

Shea,  1 88 1,  reports  a  case  of  abscess  of 
the  pancreas  with  a  large  lumbricus  ob- 
structing the  pancreatic  duct. 

Nash,  1883,  reports  a  case  in  which 
the  lumbricus  has  passed  into  the  pan- 
creas. 

Cazel  and  Vaillard,  1891,  wrote  upon 
the  maladies  of  human  parasites. 

FUNGOSITIES. 

Such  a  condition  of  the  pancreas  is  in- 
deed rare,  if  they  are  ever  present.  There 
is  much  doubt  as  to  the  true  character  of 
Norman's  case,  1848.  His  reports  are 
meager  as  to  facts,  and  his  diagnosis  not 
well  established. 

BIBLIOGRAPHY. 

Lepine  et  Cornil.  Cas  de  lymphone  du  pan- 
creas et  de  plusieurs  autres  organes.  Gaz  med. 
de  Paris,  1874,  4S»  iii)  624. 

Panarolus,  D.  Pancreas  lapidosum.  In  his 
latrologismorum,  Roma,  1652,  51. 

Gairdner,  W.  T.  Case  of  Atrophied  Pancreas. 
Monthly  Journal  Med.  Science,  London  and 
Edinburg,  1850,  xi,  i'6\. 

Yeo.  Atrophy  of  the  Pancreas;  Hydro-pneu- 
mo-thorax.  Dublin  Journal  Med.  Science,  1874, 
vi,  167. 

Shea,  J.     Lancet,  London,  i88r,  ii,  791. 

Nash,  J.  P.  British  Med.  Journal,  London, 
1883,  ii,  770. 

Cazel  et  Vaillard.  Ann.  de  PInstit.  Pasteur, 
Paris,  1891,  V,  353-361,  i  pi. 

Norman,  G,  Prov.  Med.  and  Surg.  Journal, 
1848,  654. 


CALCHJ.I  (1839-1903). 

Calculi  of  the  pancreas  are,  indeed, 
quite  frequent.  They  may  vary  in  size 
from  a  millet  seed  to  several  ounces  in 
weight.  They  are  composed  principally 
of  lime.  There  may  be  one  or  more.  One 
may  break  into  several  fragments,  each  to 
be  the  nucleus  of  the  new  formation. 
They  may  obstruct  the  duct  from  pressure, 
or  pass  into  it  and  occlude  it,  or  they  may 
escape  into  the  intestinal  tract.  They 
may  be  the  cause  of  cystic  degeneration, 
hemorrhage  and  infection.  They  may 
rupture  into  the  peritoneal  cavity,  stom- 
ach or  the  gall  bladder. 

Moret,  1835,  records  a  case  of  pancreatic 
calculus. 

Clayton,  1849,  reports  one  which  es- 
caped into  the  cavity  of  the  abdomen, 
causing  death  by  internal  hemorrage. 

Guignard,  1852,  wrote  concerning  the 
treatment  of  pancreatic  calculi. 

Henry,  1856,  and  McReady,  1856,  each 
record  a  case  of  pancreatic  calculus. 

Harris,  1858,  reports  a  case  of  athero- 
matous deposit,  and  degeneration  of  the 
pancreas. 

Labes,  1861,  records  pancreatic  obstruc- 
tion due  to  a  calculus. 

Janeway,  1872,  found  a  pancreatic  cal- 
culus, and  Curnow,  1872,  found  numerous 
calculi  in  the  pancreatic  duct. 

Gaillard,  1880,  found  a  calculus  in  the 
stomach  that  had  escaped  through  a  fistula 
(pancreatico-gastrique), 

Johnston,  18S3,  reports  on  calculus  and 
other  affections  of  the  pancreatic  ducts. 

Moore,  1883,  records  cases  of  pancreatic 
calculi. 

Crowden,  1884  ;  Chicol,  1885  ;  Virchow, 
1887  ;  Crawford,  1889,  and  Houston,  1892, 
each  report  cases  of  pancreatic  calculi. 

Weir,  1893,  removed  a  pancreatic  cal- 
culus by  manipulation.  It  was  impacted 
and  associated  with  a  cyst. 

BIBLOGRAPHY. 

Moret.  Bull.  soc.  anat.  de  Paris,  1835,  ''^i 
30  32. 

WolfT,  |.  Case  Presenting  Ossification  of  the 
Arteries  of  the  Pancreas.  Lancet,  London,  1836, 
ii,  825. 

Clayton,  O.  P.  M.  Med.  Times,  London,  1849, 
XX.  37. 

Guignard,  P.  E.  Bull.  soc.  de  med.  de  Poitiers, 
1852.  54-73- 

Henry,  O.     France  med.,  Paris,  1856,  iii,  42. 

McCready.  New  York,  Journal  of  Medicine, 
1856,  ns,  xvi,  78. 


SURGERY  OF  THE  PANCREAS. 


55 


Harris,  R.  P.  North  Am.  Med.-Chir.  Rev., 
Philadelphia,  1858,  ii,  515  517. 

Labes.  O.  Org.  f.  d.  ges.  heilk.,  Berlin,  1861, 
X,  17  28. 

Janeway,  E.  C.  Med.  Record,  New  York,  1872, 
vii,  356. 

Curnow.J.  Tr.  Path.  Soc,  London,  1872-3, 
xxiv.,  136. 

Gailliard,  L.  Bull.  soc.  anat.,  Paris,  1880, 
Iv,  191. 

Johnston,  G.  W.  Am.  Jour.  Med.  Sc,  Phila- 
delphia, 1883    ns,  Ixxxvi,  404-429. 

Moore,  N.  Tr.  Path.  Soc.  London,  1883-4, 
XXXV,  232. 

Crnwden.  British  Med.  Journal,  London,  1884, 
ii,  966. 

Chicol,  N.     Palermo,  1885,  i,  321-40 

Virchow.  Berlin  klin.  Woch.,  1887,  xxiv, 
248  250,  267,  disc. 

Crawford,  J.  P.  Jour.  Am.  Med.  As=n.  Chi- 
cago, 1889,  xii.  158-161. 

Houston.  Kansas  City  Med.  Record,  i8_^2,  ix, 
267  271. 

Weir,  R.  F.  Med.  Record,  New  York,  1893, 
xliv,  803. 

Nimier,  H.  Beitr.  zur.  path.  anat.  u.  z.  allg. 
path.,  Jena,  1894,  ^v,  351-374.  ^  ?•• 

Eichhorst.     Boll.  d.  clin.  Milano,  1894,  ^'>  3.^^- 

Shattock,  S.  G.  Jour.  Path,  and  Bacteriol., 
Edinburg  and  London,  1896-7,  iv,  219-227. 

Giudiceandrea,  V.  Policlin.,  Roma,  1896,  iii, 
M.  33,  126. 

Cipriani,  A.  Therapist,  London,  1898,  viii, 
256-258. 

Taylor,  A.  E.  Proc  Path.  Soc,  Philadelphia, 
1898-^,  ii,  129  131. 

Richardson,  M-  H.  Philadelphia  Med.  Jour- 
nal. 1900,  vi,  665  670. 

D'Arnato.  Rivista  Critica  di  clinica  Medica, 
Florence,  June  28,  1902,  p.  513 ;  July,  1902,  p.  531 ; 
July  12,  1902,  p.  545. 

CYSTS    (1730-9103). 

Cysts  of  the  pancreas  have  been  recog- 
nized for  many  years.  They  may  be  single 
or  multilocular.  The  may  remain  single, 
or,  if  multilocular,  rupture  to  form  one 
common  cyst.  They  may  contain  blood, 
serum,  pus  or  feces.  The  latter  is  some- 
times to  be  found  when  the  contents  of  a 
cyst  have  escaped  into  the  intestine,  leav- 
ing a  fistulous  tract.  The  cyst  may  rup- 
ture into  any  of  the  cavities  of  the  body, 
escape  externally,  or  become  absorbed. 

They  may  vary  in  size  from  a  drachm 
to  several  gallons. 

There  are  many  adhesions  resulting  from 
a  cyst.  The  stomach,  liver,  kidney,  spleen, 
and  omentum  are  usually  extensively  in- 
volved. 

Cysts  may  be  slow  or  active  in  their 
development,  and  many  times  accompany 
or  are  the  cause  or  the  result  of  malig- 
nancy, as  their  association  is  intimate. 

Behn,  G.  H.  De  pancreas  ejusquore. 
Argentorati,  1730. 


Parsons,  1857,  reports  a  case  of  pan- 
creatic cyst  due  to  obstruction  of  the  duct. 

Lediberdef ,  1S67,  reports  a  case  of  fibro- 
cyst  of  the  pancreas  associated  with  folli- 
cular degeneration. 

Janeway,  1878;  Walker,  1879;  Dixon, 
18S4,  and  Riedel,  1885,  each  record  a  case 
of  cystic  degeneration  of  the  pancreas. 

Senn,  1885,  wrote  on  the  surgical  treat- 
ment of  pancreatic  cysts. 

Bunham,  1885,  gave  an  address  on  peri- 
hepatitis, causing  stricture  of  the  bile  and 
pancreatic  ducts,  and  cystic  enlargement 
of  the  pancreas. 

Salzer,  1886,  considered  the  diagnosis 
of  pancreatic  cysts. 

VVolfler,  1888,  wrote  on  the  diagnosis 
and  therapy  of  pancreatic  cysts,  and  Fen- 
ger.  1888,  on  a  case  of  traumatic  cyst. 

Zielstorff,  1887;  Nichols,  1888;  Steele, 
1888;  Linder,  1889;  Karewski,  1890; 
Treves,  1890;  Martin,  1890;  Fillippoff, 
1890;  Boeckel,  1890,  aud  Savill,  1891,  re- 
port cases  of  spontaneous  rupture  of  cyst. 

Hartman,  1891  ;  Stiller,  1892,  and 
Swain,  1893,  each  report  a  case  of  pancre- 
atic cyst  or  effusion  into  the  lesser  perito- 
neal cavity. 

Tricomi,  1892  ;  Rotgans,  1892  ;  Hulke, 
1892;  Stapper,  1892;  Lloyd,  1892,  each 
record  cases  of  injury  to  pancreas  as  a 
cause  of  effusion  into  the  lesser  peritoneal 
cavity. 

Little  wood,  1892,  reports  a  case  of  trau- 
matic cyst  of  the  pancreas. 

Martin  and  Morrison,  1893;  Reeve, 
1893;  Schwartz,  1893;  Schnitzler,  1893; 
Flaischlen,  1893;  Barnett,  1893;  Stiede, 
1893,  each  report  a  case  of  pancreatic  cyst. 

Brown,  1894,  treated  a  case  of  traumatic 
pancreatic  cyst  by  abdominal  incision. 

Gussenbauer,  1894;  Middleton,  1894; 
Ott,  1894;  McBurney.  1894,  each  record 
a  pancreatic  cyst,  and  Ficher,  1894,  a  san- 
guineous cyst  of  the  pancreas. 

I3eFilHppi,  1894;  Mayo,  1894;  Strunk, 
1895;  Drobnik,  189^;  I)ryzehner,  1895; 
Mikhailoff,  189s;  Cartledge,  1895;  Rail- 
ton,  1896,  a  case  of  pancreatic  cyst  in  an 
infant. 

Lauwers,  1897;  Ogata,  1897;  Penrose, 
1897;  Coleman,  1897,  and  Horrocks, 
1897,  each  reports  a  case  of  pancreatic 
cyst  associated  with  glycosiiria,  and  gall- 
stones;   recovery. 

Bas  Arsene,  1897;  Tsigler,  1897;  Wat- 
son, 1897,  and  Lane,  1898,  record  a  case 
of  multiple  cysts  of  the  pancreas. 


56 


SUl^GEIil'  OF  THE  PAXCREAS. 


Brockman,  1898;  Cade,  1898;  Noth- 
negel,  1899;  Delageniere,  1900;  Posselt 
(multiple),  1900;  Greisen,  1900;  Mchai- 
lofF  (traumatic),  1900;  Bernard,  1900; 
Dexman  (traumatic),  19CX). 

Lisianski,  1900,  a  case  of  blood  cyst. 

BIBLIOGRAPHY. 

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KulenkamplT,  D.  Ein  fali  von  pancreas  fistel, 
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Rokitansky.  Wiener  med.  Presse,  November 
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i,  261-274. 

Leith,  R.  F.  C.  Ruptures  of  the  Pancreas, 
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1895.  ii.  770  777. 

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Cartledge,  A.  M.  Louisville  Med.  Monthly, 
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SURGERT  OF  THE  PANCREAS. 


57 


creatic  Cysts.  Orvosi.  hetil.,  Budapest,  1897, 
xli,  71. 

Lauwers.  Rfv.  de  gynec,  et  de  clin.  ab.  d., 
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Ogata,  S.  Iji.  Kwai  Ho  Ogata  Byoin,  Osaka, 
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Horrocks.     Lancet,  London,  1897,  i,  242. 

Bas,  Arsene.     Lyon,  1897. 

Indemans,  J.  W.  M.  Over  de  pathologie  en 
therapie  der  pancreas-cysten  maastricht  (Amster- 
dam), 1897,  155  p. 

Tsigler,  D.  K.   Laitop  russk.  chir.,  St.  Petersb., 

1897,  ii.  457-460. 

Watson,  L.  H.  New  England  Med.  Monthly, 
Danbury,  Conn.,  1897,  xvi,  11^9  161. 

PfaflF,  F.  Some  Observations  in  a  Case  of 
Human  Pancreatic  Fistula.  Jour.  Boston  Soc. 
Med.  Sc,  1897-8,  ii,  10. 

Rolleston,  H.  D.  Localized  Effusion  in  the 
Lesser  Sac  of  the  Peritoneum  Due  to  Pancrea- 
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Lane,  A.     Med.  Press  and  Circular,  London, 

1898,  Ixvi,  116. 

Cade  at  Jourdanet.  Province  med.,  Lyon,  1898, 
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Brockman,  D.  C.  Tri-State  Med.  Journal  and 
Practitioner,  St.  Louis,  1898,  v,  205-208. 

Lenarcic,  J.  Punctions  flussigkeit  einer  pan- 
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Hemmeter  and  Adler.  A  Chemical,  Physio- 
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Delageniere,  H.  Une  observation.  Arch, 
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133-135- 

Greisen,  L.  Ueber  einen  fall  von  pankreas 
cyste  mit  den  ersceinungen  des  choledochusver- 
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Michailoff,  N.  N.  Khirurg.,  Mosk.,  1900,  viii, 
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Berard,  L.  Presse  med.,  Paris,  1900,  ii,  28  32, 
6  fig. 

Dexman,  M.  Liecnicki  viestnik.  Zagreb., 
1900,  xxii,  1-5,  33  35. 

Lisianski,  W.  L  Vratch.,  St.  Petersb.,  1900, 
xxi.  1172- 1174. 

Lejonne  et  Milanoflf.  Ktstes  du  pancreas  re- 
trissement  du  pylore.  Bull,  et  mem.  soc.  anat., 
Paris,   1900,  ii,  406-408,  408-409. 

Fitz,  R.  H.  Multilocular  Cystoma  of  the 
Pancreas.  Am.  Jour.  Med.  Sc,  Philadelphia, 
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Gangolphe.  Deux  observations  de  kyste  du 
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129  130. 

Starck,  J.  Zwei  falle  cystischer  pankreas  ges- 
schwulste.  Beitr.  z.  klin.  chir.,  Tubingen,  1901, 
xxix,  713  730,  I  taf. 

Boelke,  Otto.  Beitrage  zur  kenntniss  der  pan- 
kreascysten.  Inaug.  Diss.,  Greifswald,  1901, 
Marz. 

Soubbotitch,  V.  Sur  un  cas  opere  de  kyste 
hematique  du  pancreas  avec  analyse  anatomo- 
pathologique.     XIII   Cong.   Internal,    de  Med., 


Sect  de  Chir.  Gen.,  1900  (Paris),  1901,  compt. 
rend..  216-219. 

Seefisch,  G.  Mittheilung,  ueber  pankreascys- 
ten.  Deutsche  ztschr.  f.  chirurg.,  Lpz.,  1901, 
lix,  153-168. 

Moynihan.  Med.  Chir.,  Manchester,  England, 
January.  1902,  p. 241. 

HEMORRHAGE    (1873-I903). 

Hemorrhage  into  the  body  of  the  pan- 
creas is  quite  frequent,  and  may  be  due  to 
trauma,  degeneration  of  one  or  more  of  its 
blood-vessels  from  disease,  external  pres- 
sure, or  the  presence  of  a  calculus  or  other 
foreign  body  within  it. 

It  may  be  sudden  or  slow  in  its  develop- 
ment, and  vary  in  amount  of  its  contents 
from  a  drachm  to  several  gallons. 

They  may  disappear  by  absorption,  rup- 
ture into  the  alimentary  tract,  peritoneal 
cavity,  into  the  bladder  or  through  the 
abdominal  wall. 

Their  contents  may  become  infected, 
and  thereby  become  pus.  Sometimes  the 
clot  becomes  organized,  to  become  benign 
or  malignant  in  character. 

Auger,  1865,  recorded  a  sanguinary  cyst 
of  the  pancreas. 

BIBLIOGRAPHY. 

Zenker.  Sitzungsh.  d.  phys.  -  med.  soc.  zu 
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SaUerwaite.  Med.  Record,  New  York,  1875, 
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Hilty.  Corbl.  f.  schweiz.  aertze,  Basel,  1877, 
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Challand  and  Rabow.  Bull.  soc.  med.  de  la 
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Kollmann,  O.  Aerztl.  Int.-bl.,  Munchen,  1880, 
xxvii,  421  424.  Verhandl.  d.  phys. -med.  ges.  in 
Wurzb.,  1880,  n  F.,  xiv,  p.  iii. 

Draper,  F.  W.  Boston  Med.  and  Surg.  Jour- 
nal, 1880,  ciii,  615. 

Harris,  J.  C.  IBoston  Med.  and  Surg.  Journal, 
1881,  cv,  593. 

Homans,  C.  D.     Ibid.,  592. 

Farge.     Bull.   soc.   de   med.  d'Angers  (1882), 

1885,  n  s.  X,  188-193. 

Amidon,  R.  W.  "  Boston  Med.  and  Surg.  Jour- 
nal, 1886,  cxv,  594. 

Osier  and  Hughes.  Semi-Monthly  Journal, 
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1886,  i,  7.  Tr.  Assn.  Am.  Phys.,  Philadelphia, 
i88b,  i,  244-251,  Med.  News,  Philadelphia,  1888, 
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Fitz,  R.  H.  Med.  Record,  New  York,  1889, 
XXXV,  197-204. 

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1889,  cxxi,  606. 

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Fitz,  R.  H.  Middleton  Goldsmith  Lecture. 
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Formad,  W.  F.  Univ.  Med.  Magazine,  Phila- 
delphia, 1891  92,  iv,  49-52. 

Day,  F.  L.  Boston  Med.  and  Surg.  Journal, 
1892,  cxxvii,  569-571. 


58 


SURGERT  OF  THE  PANCREAS. 


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1895,  cxxzii,  354. 

Chantemesse  et  Griffon.  Bull.  Soc.  anat.  de 
Paris,  189!;,  Ixx.  578-586. 

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McPhedan,  A.    Canad.  Practitioner,  Toronto, 

1896,  xxi,  650  656. 

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6s,  ii,  106-113. 

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1898,  i,  1452. 

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p.  1816,  1898. 

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1898,  los,  V,  1896  240. 

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1899,  xiii,  126-133. 

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Bryant,  J.  H.  Lancet,  London,  1900,  ii,  1341- 
1345,  I  ch.,  I  fig. 

Ros.'bach.  Inaug.  Diss.,  Erlangen, 1900,  August 
and  September. 

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Kratter,  J.     1899,  1900,  Th.  2,  Halfte,  550. 

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125-130. 


Opie,  E.  L.  Johns  Hopkins  Hospital  Bulletin, 
Baltimore,  1901,  xii,  i8i  188. 

Subbotic,  V.  Deutsche  ztschr.  f.  chir.,  Lpz., 
1901,  lix    197-200. 

Halstead,  W.  S.  Johns  Hopkins  IIosp.  Bull., 
Baltimore,  lyoi,  xii,  179  182. 

Batchelor,  W.  A.  Hemorrhagic  Pancreatitis; 
Operation;  Recovery.  Med.  News,  New  York, 
August  9,  1902,  Vol.  81,  No.  6,  p,  249-250. 

Freeman.  A  Case  of  Gangrenous  Hemorrhage 
Pancreatitis.  Denver  Med.  Times,  April,  1902, 
p.  463. 

ABSCESS    (1829-I9O3). 

Abscess  of  the  pancreas  may  be  either 
primary  or  secondary,  single  or  multiple. 
The  most  common  form  of  abscess  of  the 
pancreas  is  infection  of  some  pre-existing 
pathologic  condition,  such  as  serous  or 
sanguineous  cysts  or  calculi,  tuberculosis, 
parasites,  injuries  or  foreign  bodies.  Their 
contents  may  vary  from  a  few  minims  to 
several  pounds.  They  may  rupture  into 
the  stomach,  intestinal  tract,  perineal, 
pleural,  mediastinal  or  pericardial  cavities, 
into  the  urinary  bladder  or  tnrough  the 
abdominal  wall.  They  are  usually  retro- 
peritoneal. 

Berrende,  1829,  records  an  ulcer  of  the 
pancreas. 

Fletcher,  1848;  Roddick,  1869,  and 
Smith,  1870,  each  report  a  case  of  abscess 
of  I  lie  p  iiicreas. 

Frison,  1875  records  a  very  interesting 
case  of  pancieatic  abscess,  associated  with 
icterus  from  retention  of  bile  in  a  case  of 
diabetes. 

Counnaille,  1876,  mentions  a  similar 
case. 

Chiari,  1S76,  records  a  case  of  seques- 
tration of  the  pancreas  with  a  round  per- 
forating ulcer. 

Moore,  1881,  records  two  cases  of  pan- 
creatic abscess. 

Musser,  1883,  and  Daraignez  each  re- 
cord a  case  of  pancreatic  abscess  due  to 
thrombosis  of  the  portal  vein. 

Rosborg,  1885,  reports  a  case  of  chronic 
suppurative  induration,  peripancreatitis, 
adhesion  nephritis,  and  chronic  parenchy- 
matous gastritis. 

Graeve,  1891,  mentions  a  case  of  sup- 
purative pancreatitis  associated  with 
icterus  and  pericarditis. 

Whitton,  1891,  records  an  abscess  of 
the  pancreas,  and  Walsh,  1893,  a  celiot- 
omy for  ab-^cess  ot  the  pancreas,  with  the 
report  of  a  case. 

Musser,  1894,  reports  a  sub-diaphragm- 
atic   abscess    of    the    pancreas,    with    re- 


SURGERY  OF  THE  PANCREAS. 


59 


marks  on  effusions  in  the  lesser  peritoneal 
cavity. 

Thayer,  1895,  gives  a  case  of  acute  pan- 
creatitis, parapancreatic  abscess  and  dis- 
seminated fat  necrosis. 

Atkinson,  1895,  gives  his  notes  on  a 
case  of  acute  suppurative  pancreatitis, 
with  report  of  necropsy. 

Fowler,  1896,  notes  a  case  of  suppura- 
tive pancreatitis,  and  parapancreatic  ab- 
scess ;  diagnosis  made  by  exploratory  ab- 
dominal section. 

Faivre,  1897;  Elienne,  1898;  Hulshizer, 
1898;  Sikora,  1898;  Marwedel,  i90i,and 
Falkenstein,  1901,  each  report  a  case  of 
abscess  of  the  pancreas. 

BIBLIOGRAPHY. 

Berrends,  C.  A.  G.  In  his  Op.  Postumorum. 
Borol.,  1828,  i,  263-269. 

Mayo-Percival.  Outlines  of  Human  Pathol- 
ogv,  p.  409,  London,  1836 

Perle.  De  pancreate  ejuFque  morbis.  Dissert. 
Bern!..  1837. 

Fletcher.  Prov.  Med.  and  Surg.  Journal, 
London,  1848    20. 

Kilgour,  J.  London  Journal  of  Medicine,  1850, 
ii,  1052-1057. 

Raboli.     Schmidt's  Jahrbucher,  1859,  p.  177. 

Cases.  Suppurative  pancreatitis  mit  durch- 
bruch  in  den  magen  und  zwolfllngerdarm  wo- 
durch  ein  spulvurm  in  der  milzvene  gelangte 
leberabscess.  Tod.  Ber.  d  k.  k.  krankenanst., 
Rudolph  Stiftung  in  Wien  (1868',  1869,  301-304. 

Roddick,  T.  G.  Canada  Med.  Journal,  Mon- 
treal, 1869.  V,  385  390. 

Smith,  W.  Dublin  Qiiarterlj  Journal  of  Medi- 
cine and  Surgery,  1870,  i,  201. 

Frison,  V.  Rec.  de  mem.  de  med.  mil.,  Paris, 
1875,  xxxi,  262-269. 

Counnaille,  A.     Monit.  sclent.,  Paris,  1876,3s, 

iii.  375  383- 

Chiari,  H.  Wien.  med.  Woch.,  1876,  xxvi, 
293  294,  St.  George's  Hospital  Reports. 

Frison.  Recniel  de  Mir.  de  Med.,  Mil.  Mai- 
Juni,  1876,  1877-8,  London,  1879,  ix,  95. 

Moore,  N.  Tr.  Path.  Soc.  London,  1881, 
xxxiii    186  189. 

Shea.  Lancet,  November  5,  1881.  Abscess  of 
the  Pancreas,  Lancet,  London,  1882,  i,  los- 

Musser,  J.  H.  Tr.  Path.  Soc,  Philadelphia 
(1883-5),  1886,  xii,  66-72. 

Rosberg,  C.  A.  Hygiea,  Stockholm,  1885, 
xlvii,  274-276. 

Daraignex  Jour,  de  med.  de  Bourdeaux,  1887  8, 
xvii,  479. 

Graeve,  H.     Upsala  lakare  Forh.,  1891  2,  xxvi, 

432  435- 

Whitton,  T.  B.  Australia  Med.  Gazette,  Syd- 
ney, 1891  2,  xi,  276. 

Walsh,  J.  E.  Med.  News,  Philadelphia,  1893, 
Ixiii,  737. 

Musser,  J.  H.  University  Med.  Magazine, 
Philadelphia,  1894-5,  vii,  375-379,  i  pi. 

Thayer,  W.  S.  Am.  Jour.  Med.  Sc,  Philadel- 
phia, 1895,  ns.  ex,  396  405 

Atkinson,  L  E.  Jour.  Am.  Med.  Assn.,  Chi- 
cago, 1895,  xxiv,  999-1002. 


Fowler,  G.  R.  Brooklyn  Med.  Journal,  1896, 
X,  223-230. 

Faivre  d'Arcier,  C.  M.  J.     Nancy,  1897. 

Etienne,  G.  Arch,  de  med.  exper.  et  d'anat. 
path.,  Paris,  1898,  x,  177-213. 

Hulshizer,  A.  H.  Philadelphia  Med.  Journal, 
1898,  i,  1115-1117. 

Sikora,  P.     Report  d.  hop.,  Paris,   1898,  Ixxi, 

729  734-  ,     . 

Marwedel.  Munchen  med.  Woch.,  1901,  xlviii, 

11-14. 

Falkenstein.     Inaug.  diss.,  Kiel,  1901,  Mai. 

SYPHILIS  (1878-1903). 

Syphilis  of  the  pancreas  is  uncommon, 
there  having  been  but  a  few  cases  reported. 
It  is  probably  never  primary,  always  sec- 
ondary, and  may  alone  be  involved.  It 
seems  to  have  great  resistance  to  this  as 
well  as  other  disease.  It  is,  however, 
more  frequently  involved  than  is  generally 
supposed.  It  has  not  been  given  careful 
consideration  until  recent  years.  The 
tissue  becomes  hard,  localized  of  general. 
A  part  or  all  of  the  gland  may  be  in- 
volved. 

It  is  amenable  to  syphilitic  remedies, 
and  is  probably  as  much  influenced  by 
them  as  any  other  organ. 

It  is  difficult,  however,  to  determine 
syphilitic  disease  of  the  pancreas,  except 
by  autopsy. 

Huber,  1878,  records  a  case  of  syphilis 
of  the  pancreas,  and  Schlagenhaufer^ 
1895,  one  of  acquired  syphilitic  pancrea- 
titis, induration  and  gumma. 

Cesaris-Demel,  1895,  records  a  case  of 
adenoma,  and  induratio  pancreatitis  of 
syphilitic  origin. 

Lounin,  1900,  records  a  case  of  heredi- 
tary syphilitic  pancreatisis. 

BIBLIOGRAPHY. 

Huber,    K.     Arch.   d.   heilk.,   Lpz.,  1878,  xix, 

430-34- 

Schlagenhaufer,  F.     Arch.  f.  dermat.  u.  syph., 

Wien  u.  Lpz.,  1895,  xxxi,  43  48. 

Cesaris  Demel,  A.  Arch,  per  le  sc.  med.,  To- 
rine,  1895,  xix  225-237,  i  pi. 

Lounin,  N.  Bolnitsch  gaz.  Botkina,  St.  Peters- 
burg, 1900,  xi,  1036  1044. 

Gianelli,  L.  Monitore  zool.  ital.,  Firenze, 
1901,  xii,  207. 

TUBEHCULOSIS     (1835-I9O3). 

Tuberculosis  of  the  pancreas  is  rare.  It 
may  be  primary  or  secondary,  more  fre- 
quently secondary.  When  primary,  the 
source  of  infection  is  probably  from  the 
alimentary  tract  through  the  panrreatic 
duct.  When  secondary,  it  is  usu.ill}  from 
adjacent  tissues. 


6o 


SURGERT  OF  THE  PANCREAS. 


There  may  be  one  or  more  foci,  and 
they  may  remain  so  or  unite  to  form  one 
common  cyst  containing  pus,  serum,  blood 
or  caseous  matter.  The  caseous  deposits 
may  undergo  calcareous  degeneration.  If 
cystic  the  fluid  may  escape,  by  absorption 
or  rupture. 

Martland,  1825,  mentions  a  case  of  tu- 
berculosis ot  the  pancreas  associated  with 
tuberculosis  of  the  liver. 

Duplay,  1834,  writes  rather  extensively 
upon  a  case  in  which  there  was  tuberculo- 
sis of  the  pancreas,  in  which  there  was 
great  induration  and  tumefaction ;  also 
duodenitis. 

Berlyn,  1842;  Aran,  1846;  Sandras, 
1848U  Barlow,  1875;  Bruen,  1885;  Car- 
not,  1897  ;  Lefas,  1900,  each  report  a  case 
of  tuberculosis  of  the  pancreas. 

BIBLIOGRAPHY. 

Martland,  R.  Edinburgh  Med.  and  Surg.  Jour- 
nal, 1825,  xxiv,  73. 

Duplay,  A.  Arch.  gen.  med.,  Paris,  1834,2s, 
iv,  41  r  418. 

Berlyn,  C.  Med.  cor-bl.  Rhein  u.  Westfal 
Aerzte,  Bonn,  1842,  i,  321  329. 

Aran,  F.  A.  Arch.  gen.  de  med.,  Paris,  i8j6, 
ill,  61-75. 

Sandras.  Rev.  med.  franc,  et  etrang.,  Paris, 
1848,  i,  279-293. 

Barlow,  T.  Tr.  Path,  soc,  London,  1875-76, 
xxvii,  173-175. 

Bruen'  E.  T.  Polyclinic,  Philadelphia,  1885- 
6,  iii,  7. 

Carnot,  P.  Compt.  rend.  acad.  d.  sc,  Paris, 
1897,  cxxv,  1135-1137. 

Lefras,  E.  Arch.  gen.  de  med  ,  Paris,  1900,  iv, 
312  323,  2  fig. 

Mays.     Outlines  of  Human  Pathology,  p.  410. 

GANGRENE    (1884-I9O3). 

Gangrene  of  the  pancreas  is  infrequent. 
A  part  or  all  of  the  gland  may  be  involved. 
It  may  result  from  injury,  obstruction  of 
its  ducts,  pressure  from  neoplasms,  or 
otherwise. 

It  may  be  primary  or  secondaay,  usually 
secondary.  It  may  also  result  from  the 
presence  of  a  calculus,  which  has  caused 
pressure  upon  its  blood-vessels  or  ducts. 

Infection  is  also  the  cause  of  gangrene 
of  the  pancreas. 

Gangrene  may  result  in  the  develop- 
ment of  any  neoplasm,  benign  or  malig- 
nant. 

Mader,  1884,  records  a  case  of  gangrene 
of  the  pancreas  due  to  thrombosis. 

Von  Bonsdorff,  1895,  reports  a  case  of 
acute  gangrene  of  the  pancreas. 

Sievers,  1895,  writes  of  a  case  of  acute 
gangrene. 


Guinard,  1898,  mentions  a  case  of  sup- 
purativ'e  and  gangrenous  pancreatitis. 

Brennecke,  1898,  reports  two  ca«;es  of 
gangrenous  pancreatitis  with  disseminated 
fat  necrosis. 

BIBLIOGRAPHY. 

Chiari.  Wiener  med.  Woch.,  No  6  and  7, 
1891. 

Rosenb  ch.     Centralblatt  Sur.  Surg.,  1882. 

Prince.  Boston  Med.  and  Surg.  Journal,  July, 
1883. 

Mader.  Ber.  d.  k.  k.  krankenanst.  Rudolph- 
Siiftung  in  Wien  (1SS4.),  1885.  371. 

Von  BonsJorfF,  11.  F'inska  lak  salsk  handl. 
Helsingsfor,  1895,  xxxvii,  607-613. 

Guinard,  A.  Bull,  et  mem.  soc.  d.  chir., Paris, 
1898,  xxiv,  380-386. 

Brennecke,  H.  A.  Jour.  Am.  Med.  Assn.,  1898, 
XXX,  1329  1332. 

Israel.     Virchow's  Arch.,  vol.  Ixxxiii,  p.  181. 

Trayfoyer  and  Heronals. 

CARCINOMA    (1789-I9O3). 

This  is  the  most  common  form  of  cancer 
of  the  pancreas,  and  more  frequently  in- 
volves its  head. 

All  forms  of  carcinoma  have  been  found 
in  this  organ,  both  of  primary  and  second- 
ary origin. 

The  first  is  not  so  frequent  as  the  second, 
and  in  either  the  stomach  is  frequently 
involved,  owing  to  their  intimate  relation. 

Malignancy  of  the  pancreas  is  often 
associated  with  cysts  of  it,  and  when  pres- 
ent is  no  doubt  a  cause  of  the  formation 
of  the  cyst,  and  many  times  vice  versa. 

The  duodenum  is  frequently  involved 
with  pancreatic  cancer. 

The  pancreas  is  subject  to  the  same  laws 
concerning  malignancy  as  other  organs  of 
the  body. 

Da  Costa  says  that  cancer  of  the  pan- 
creas is  more  frequent   in  the  male. 

Bright  reports  several  cases  of  carcinoma 
of  the  pancreas  in  which  fatty  diarrhea 
was  present.  He  concludes,  therefore,  that 
it  indicates  disease  of  the  pancreas. 

BIBLIOGRAPHY. 

Van  Doeveren,  A.  J.  De  pancreate  carcino- 
matoso  eo  in  loco  ubi  ipsi  ventriculus  accumbit 
cum  erosione  hujus  visceris  et  sanguinis  demum 
omnis  intra  ipsius  et  interestinorum  capacitatem 
elTusione.  In  his  Observat.  path.  anat.  Lugd. 
Bat.,  1789,  35  49,  3  pi. 

Brassier,  B.  Historie  d'une  tumeur  squirrheuse 
qui  renfermait  dans  son  sein  I'aorte  la  veine  cave 
une  port  portion  du  pancreas  et  le  pylo  pylore 
eclaree  par  I'ouverture  du  cadavre.  Jour.  gen. 
de  med.  chir.  et  pharm.,  Paris,  1817,  lix,  239  256. 

Sandwith,  T.  Edinb.  Med.  and  Surg.  Journal 
1820,  xvi,  380. 

Recamier.     Rev.  Med.,  1830. 


SURGER2'  OF  THE  PAXCREAS. 


6i 


Bayne,  J.  H.  Am.  Jour.  Med.  Science,  Phila- 
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Bright.  Med.-chir.  Trans.,  Vol.  xviii,  p.  I, 
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Suche,  F.  R.     Nonnulla  Berolini,  1834. 

Sjm,  J.  Edinb.  Med.  and  Surg.  Journal,  1835, 
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Muehry,     Casper's  Woch.,  No.  x,  1835. 

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433.  449- 

Hultgren,  C.  W.     Lundae.  1837. 

Dickson,  D.  J.  H.  Med.  Chir.  Rev.,  London, 
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Kruger-Hwnsen.  Ein  wort  uber  Casper's  Cur 
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Knowleton,  C.  Boston  Med.  and  Surg.  Jour- 
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Battersby,  F.  Dublin  Quarterly  Journal  Medi- 
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62 


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SARCOMA    (1S68-I903). 

vSarcoma  of  the  pancreas  may  be  pri- 
mary or  secondary,  usually  primary,  as 
indicated  by  reported  cases.  It  is  usually 
the  tail  that  is  involved. 

Sarcoma  of  the  piincreas  is  usually  r>f 
rapid  growth,  and  seldom  undergoes  c)  b.ic 
degeneration, 


SURGERT  OF  THE  PANCREAS. 


63 


Historical. — Paulicki,  1868,  reports  a 
case  of  primary  sarcoma  of  the  pancreas. 

In  the  Bulletin  is  to  be  found  the  report 
of  a  case  of  lympho-sarcoma. 

Machado,  1883,  records  a  case  of  sar- 
coma of  the  pancreas,  as  does  also  Chiari 
during  the  same  year, 

Kuhn,  1887,  mentions  a  case  of  primary 
sarcoma  of  the  pancreas. 

Ricketts,  B.  M.,  1889,  had  a  case  of 
primary  sarcoma  of  the  pancreas. 

Garda-Mansilla,  1892,  records  a  pro- 
gressive sarcoma  of  the  pancreas,  and 
Ehrmann,  1896,  and  Greene,  1898,  each 
one  of  primary  sarcoma  of  pancreas.  The 
first  was  of  its  tail. 

Italia  Edorado,  1900,  records  a  pri- 
mary pancreatic  sarcoma. 

Jamison,  1902,  one  of  a  similar  nature. 

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Pepper,  J.     Ferl.  kiin.  woch.,  1896,  xlvi,  581. 

Stoicescu,  G.  Romania  med.  Bucuresci,  iv, 
2,  41. 

Jamison,  W.  B.  Proc.  Path.  Soc,  Philadel- 
phia, 1897-8,  ns,  I,  301. 

Leven,  G.     Bull.  soc.  anat.,  Paris,  1897,  Ixxii, 

951-954- 

Metarazzo  Carveni,  G.  Corriere  san  Settim, 
Milano,  1897,  '^i"'  No.  19,  4. 

Lamb,  D.  S.  Nat.  Med.  Review,  Washington, 
1897-8.  vii,  268. 

Bard  et  Pic.  Rev.  de  med.  Paris,  i8g7,  929  953. 
Boston  Med.  and  Surg.  Journal,  1897,  cxxxvi, 
578-580. 

Guillou  Francis.     Paris,  1898,  78  p..  No.  424. 

Veratrate  et  Danel.  Jour.  d.  sc.  med.  de  Lille, 
1898,  i,  630-635. 

Routier.  Bull,  et  mem.  chir.,  Paris,  1898, 
xxiv,  152-154. 

Rigot,  H.  Loire  med.,  St.  Etienne,  1898, 
xviii,  122. 

Arnold,  J.  P.  Tr.  Path.  Soc,  Philadelphia, 
1898,  xviii.  127-129. 

Guillou,  F.  Gaz.  hebd.  de  med.,  Paris,  1898, 
iii,  841-843. 

Bielogolovvv,  A.  A.  Bolnitsch.  gaz.  Botkins, 
St.  Petersb.,  1898,  ix,  1633.35. 

Darrach  and  Davis.  Univ.  Med.  Magazine, 
Philadelphia,  1898,  9,  xi,  22-27. 

Monod,  R.  Bull.  et.  mem.  soc.  anat,,  Paris, 
1900,  ii,  136-139. 

Morlot,  E.  Anatomiques  Bourgogne  med. 
Dijon,  1900,  viii,  48  50. 

Pic  et  Tolot.  Province  med.,  Lyon,  1900,  xv, 
277-279,  294-297,  301-305. 

Robson,  A.  W.  M.  Lancet,  London,  1900,  ii, 
235  240. 

Vance,  A.  M.  Louisville  Monthly  Journal  of 
Medicine  and  Surgery,  1902,  p.  416  417. 

HERNIA     (1856-I9O3). 

Hernia  of  the  pancreas  usually  results 
from  penetrating  wounds  in  the  back.  It 
may,  however,  be  congenital.  It  may 
become  gangrenous  as  the  result  of  stran- 
gulation, and  undergo  a  spontaneous  re- 
covery. The  strangulated  portion  has  in 
few  instances  been  successfully  removed 
by  ligature  or  otherwise. 

Cecchini,  1886,  records  a  case  of  con- 
genital ectopia  of  the  pancreas. 

Pererirao  Guimaraes,  1896,  mentions  a 
case  of  traumatic  hernia  of  the  pancreas, 
as  does  Foy,  1897,  also. 

Hondal,  1897,  records  a  curious  case  of 
prolapse  of  the  pancreas. 

BIBLIOGRAPHY. 

Labedorie.     Gaz.  des  hopt.  aux..  No.  2,  1856. 

Dagu.  Med.  and  Surg.  Reporter,  August  22, 
1874. 

Kleberg.  Langenbeck's  Arch  fur  Chir.,  vol. 
ix,  p.  523.     Med.  and  Surg.  History  of  the  War 


of  the  Rebellion,  Part  ii,  vol.  ii.  Surg.  History, 
p.  158,  gives  two  cases  of  hernia  of  the  pancreas, 
following  gun-shot  injury. 

Nussbaum.  Die  verletzungen  des  um  Terle- 
leibes,  1880. 

Cecchini,  S.  Rassegna  di  sc.  med.  Modena, 
1886,  i,  314-325. 

Pererira  Guimaraes.  Prog,  med.,  Pf  ris,  1896, 
3s,  iv,  236. 

Foy,  G.  Med.  Press  and  Circular,  London, 
1897,  ns,  Ixiii,  557. 

Honda,  T.  Chiugai  Iji  Shinpo,  Tukio,  1897, 
xviii.  No.  411,  15  22. 

SURGERY    (1856-1903). 

Pancreatotomy  is  done  for  the  evacua- 
tion of  all  kinds  of  cysts,  removal  of  for- 
eign bodies  or  calculi ;  all  kinds  of  neo- 
plasms, malignant  or  benign  ;  and  ligation 
of  the  pancreatic  arteries  or  ducts. 

The  trocar  should  never  be  used  in  pan- 
creatic cysts  only  when  the  abdomen  has 
been  previously  opened. 

Pancrecctomy  is  I  he  removal  of  a  por- 
tion or  all  of  the  pancreas  for  hernia,  gan- 
grene, laceration  or  otherwise. 

Pancreopcxy  consists  in  fixing  the  pan- 
creas, healthy  or  diseased,  in  its  normal 
position  or  in  the  abdominal  wall,  for  dis- 
lodgement,  laceration,  cysts  or  other- 
wise. 

Pancreorrrapliyls  suturing  the  pancre- 
atic tissue  for  lacerated  or  incised  wounds 
produced  by  accident  or  surgical  opera- 
tions. 

The  suturing  of  walls  of  cysts  to  the 
abdominal  wall  is  not  properly  included 
in  pancreopexy. 

Death  finally  results  from  complete  ex- 
tirpation of  pancreatic  tissue. 

Subcutaneous  or  peritoneal  implanta- 
tion of  pancreatic  tissue  (in  the  absence 
of  the  original  pancreatic  tissue)  will 
maintain  life  indefinitely. 

His/orical.— One  of  the  first  memoirs 
on  extirpation  of  the  human  pancreas  is 
by  Bernard  and  Colin,  1856;  Allen,  1876, 
contributed  another  in  which  he  spoke 
of  the  possibilities  of  exsection  of  the 
pancreas. 

Zukowski,  1881,  made  a  laparotomy  for 
a  pancreatic  cyst,  and  Bozeman,  during 
the  same  year,  removed  a  cyst  of  the 
pancreas  in  the  same  manner,  weighing 
twenty  and  one  half  pounds. 

Gussenbauer,  1883,  performed  an  oper- 
ation for  a  cyst  of  the  pancreas.  In  the 
Transactions  of  the  American  Surgical 
Association,  is  to  be  found  a  most  inter- 
esting report  on  the  surgery  of  the  pan- 


66 


SURGERY  OF  THE  PANCREAS. 


creas  based  upon  experimental  and  clinical 
researches. 

Bull,  1887,  reports  a  case  of  pancreatic 
cyst  treated  successfully  by  incision  and 
drainage.  The  patient  subsequently  died 
from  diabetes. 

Tremaine,  18S8,  was  successful  in  re- 
moving a  pancreatic  cyst  and  preserving 
the  life  of  the  patient. 

Cathcart,  1889,  reports  a  case  of  trau- 
matic cyst  of  the  pancreas  in  which  rup- 
ture occurred  after  the  introduction  of  a 
hypodermic  needle.  He  made  a  laparotomy 
with  recovery.  The  danger  is  thus  shown 
that  a  needle  or  trocar  should  never  be 
introduced  into  such  a  cyst  unless  its  wall 
is  extra-peritoneal. 

Parkes,  1889,  drained  such  a  cyst,  and 
Amandale,  1889,  was  fortunate  in  having 
his  case  recover  after  abdominal  section 
and  drainage. 

Minkowski,  1890,  extirpated  a  cyst,  and 
Pitt  and  Jacobson,  1S90,  drained  one, 
with  recovery,  by  abdominal  incision. 

Agnew,  1S90,  and  Briggs,  1890,  each 
removed  a  pancreatic  cyst  with  recovery. 

Lancereaux,  1891,  performed  complete 
ablation  of  the  pancreas  in  a  case  of 
diabetes,  and  Hedon,  during  the  same 
year,  studied  the  effect  upon  the  general 
nutrition  after  extirpation  of  the  pancrens. 

Aldehoff,  of  the  same  year,  also  noted 
the  effects  of  extirpation  in  cases  of  dia- 
betes mellitus. 

Pitt  and  Jack<on  had  recovery  follow  a 
laparotomy  and  drainage  for  a  pancreatic 
cyst. 

Littlewood,  1891,  records  a  case  of  trau- 
matic cyst  of  the  pancreas  successfully 
treated  by  stitching  the  cyst  wall  to  the 
abdominal  parietes,  and  drainage.  He 
gives  the  analysis  of  the  pancreatic  fluid 
subsequently  collected. 

Richardson,  1891,  treated  a  pancreatic 
cyst  by  laparotomy  and  drainage,  with 
recovery  from  operation,  and  apparently 
from  the  disease,  but  there  was  recurrence, 
with  perforation  of  the  stomach,  and 
death,  verified  by  autopsy. 

A  cyst  treated  by  Richardson  and  Mum- 
ford,  1892,  in  the  same  way  recovered, 
and  another  such  case  by  Richardson  re- 
covered in  1895. 

Gley,  1S93,  noted  the  alterations  caused 
by  extirpation  of  the  pancreas  in  diabetics. 

Grifhn,  1S93,  made  an  abdominal  sec- 
tion with  recovery  in  a  case  of  pancreatic 
cyst. 


Sharkey  and  Glutton,  1893,  also  suc- 
cessfully removed  a  pancreatic  cyst. 

Ghurton,  1893,  incised  a  pancreatic  cyst 
in  a  case  of  diabetes.  Death  one  year 
after  operation.  There  was  atrophy  of 
the  pancreas. 

Johansson,  1S93,  extirpated  the  pan- 
creas, and  Sandmeyer,  1891,  made  a  par- 
tial extirpation  of  the  pancreas. 

Ilerczel,  1894.,  successfully  operated  for 
a  pancreatic  cyst,  while  Thomas,  1894, 
cured  by  aspiration  a  case  of  traumatic 
pancreatic  eft'usion  into  the  lesser  perito- 
neal cavity. 

Ashurst,  1894,  made  a  pancreatotomy 
followed  by  recovery  for  a  large  suppur- 
ating cyst. 

Thoren,  1896,  made  a  partial  resection 
of  a  pancreatic  cyst  and  sutured  its  wall 
to  that  of  the  abdomen. 

Malcolm,  1897,  completely  removed  a 
multilocular  cyst  of  the  pancreas  with 
recovery. 

Parry,  Dunn  and  Pitt,  18S7,  made  a 
laparotomy  for  acute  hemorrhagic  pan- 
creatitis and  fat  necrosis  of  the  omentum, 
resulting  in  death  and  autopsy. 

Randall,  1S9S,  successfully  treated  by 
incision  and  drainage  a  pancreatic  cyst. 

Gushing,  1898,  records  a  case  of  trau- 
matic rupture  of  the  pancreas,  with  the 
furnuilion  of  a  Iieniurrhagic  cyst.  Oper- 
ation followed  by  a  pancreatic  fistula  and 
recovery. 

Pollard,  1899,  reports  three  cases  of 
cysts  of  the  pancreas  treated  by  incision 
and  drainage  through  the  anterior  wall. 

Manges,  1899,  records  a  case  of  acute 
pancreatitis,  dis-seminated  fat  necrosis  of 
omentum  and  peritoneum  ;  laparotomy  ; 
recovery. 

Ransohoff,  1901,  records  two  cases  of 
cystic  adenoma  of  the  pancreas.  He  ex- 
tirpated the  cyst  in  one  and  sutured  the 
wall  of  the  other  to  the  wall  of  the  abdo- 
men. Death  ensued  several  months  after 
the  second  operation  as  result  of  cancer. 

Munro,  1901,  reports  a  case  of  recovery 
after  operation  for  acute  pancreatitis. 

Tilton,  1901,  writes  upon  the  operative 
treatment  of  diseases  of  the  pancreas. 

Layne,  1902,  opened  abdominal  wall, 
incised  that  of  a  pancreatic  cyst,  drained 
and  sutured  the  wall  of  the  cyst  to  that  of 
the  abdomen,  with  recovery  of  the  patient. 

CONCLUSIONS. 

I.  The    pancreas    is  constant    in   man, 


SrRGERT  OF  THE  PANCREAS. 


67 


and  a  normal  one  is  seldom  in  an  abnor- 
mal position. 

2.  The  size,  shape,  number  of  lobes, 
bifurcations,  ducts  and  their  openings 
into  the  intestinal  tract  vary  consider- 
ably. 

3.  Its  physiology  remains  undeter- 
mined. 

4.  It  is  subject  to  about  the  same  path- 
ologic changes  as  the  other  glands. 

5.  The  presence  of  calculi  demand  ex- 
ploration of  the  gland  and  removal  of  the 
calculus. 

6.  Small  cysts  of  any  character,  and 
large  ones  when  pedunculated,  should  as 
a  rule  be  extirpated. 

7.  Large  cysts,  of  any  character,  when 
not  pedunculated,  should  be  sutured  to 
the  abdominal  wall  and  drained  through  it. 

8.  Gujumata  of  the  pancreas  are  amen- 
able to  syphilitic  remedies. 

9.  Tubercular  nodules  should  be  ex- 
cised. 

10.  Gangrenous  portions  of  the  pan- 
creas can  and  should  be  removed. 

11.  Xcoplastns,  malignant  or  benign, 
should  be  extirpated. 

12.  A  small  portion  of  the  pancreas 
will  functionate  enough  to  maintain  life. 

13.  The  entire  gland  should  not  be  re- 
moved except  in  extreme  cases  of  malig- 
nancy, when  a  piece  of  animal  pancreas 
should  be  transplanted  subcutaneously. 

14.  The  efficacy  of  such  a  procedure  is 
not  certain. 

15.  Hernia  of  the  pancreas,  when 
gangrenous,  should  be  amputated  and 
sutured  subcutaneously. 

17.  Incarcerated  hernia  as  a  rule  should 
be  left  alone. 

17.  Gun-shot,  lacerated  and  incised 
wounds  of  the  pancreas  should  be  packed, 
sutured,  or  vessels  ligated,  one  or  all  if 
necessary. 

18.  It  is  but  a  few  such  cases  in  which 
it  might  be  necessary  to  suture  the  lacer- 
ated pancreas  to  the  abdominal  wall. 

19.  It  is  probably  only  when  wounded 
posteriorally  that  such   will  be   necessary. 

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72 


SURGER7'  OF  THE  PANCREAS. 


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H 


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1 11.^ — Surgery  of  the   Diaphragm. 


ANATOMY  AND   PHYSIOLOGY    (1661-I9O3). 

The  diaphragm  is  the  chief  characteris- 
tic in  mammals  (among  them  man)  ;  it 
forms  a  thin  muscular  fibrous  partition 
between  the  abdominal  and  thoracic  cavi- 
ties. It  is  the  base  of  a  closed  cavity  con- 
taining the  heart  and  lungs. 

It  is  absent  or  rudimentary  in  birds. 

Amphibia  and  animals  below  them  in 
scale  of  structure  have  no  diaphragm. 

First  trace  is  in  the  crocodile  and  birds  ; 
even  in  birds  it  is  not  complete. 

In  cetacea  the  centrum  tendineum  is 
almost  obsolete. 

It  has  four  divisions — central  tendineum, 
middle,  right  and  left  leaflet.  Its  fibres 
vary  greatly  in  length;  those  from  the 
middle  leaflet  arising  from  the  ensiform 
appendix  are  short,  while  those  of  the 
right  and  left  leaflets  are  much  longer. 

They  arise  from  the  whole  of  the  inter- 
nal circumference  of  the  thorax,  and  at- 
tached to  the  inner  surface  of  the  cartilages, 
and  bony  portions  of  the  six  or  seven  in- 
ferior ribs  interdigitating  with  the  trans- 
versal is;  and  beiiind  to  two  aponeurotic 
arches,  the  ligamentum  arcuatum  exter- 
num, and  internum,  and  to  the  lumbar 
vertebra. 

The  fibres  of  the  diaphragm  touch  those 
of  the  psoas  and  quadratus  lumborum 
muscles. 

The  diaphragm  is  perforated  by  the 
esophagus,  vena  cava  and  aorta.  The 
right  cons  transmits  the  sympathetic,  and 
the  greater  and  lesser  splanchnic  nerves 
on  the  right  side. 

The  left  cons,  the  greater  and  lesser 
splanchnic  nerves  of  the  left  side,  and  the 
vena  azygos  minor. 

There  is  a  deficiency  in  the  fibres  of  the 
diaphragm  about  the  ensiform  appendage 
and  the  cartilages  of    the    adjoining  ribs. 


owing  to  areolar  tissue,  pleura  upon  the 
thoracic  side,  and  peritoneum  on  the  ab- 
dominal side. 

The  blood  supply  is  from  the  right  and 
left  phrenic  arteries.  They  arise,  as  a 
rule,  independently  from  the  aorta  or  the 
celiac  axis,  sometimes  from  the  renal  ar- 
tery. There  may  be  but  one  origin,  the 
artery  bifurcating  from  one  to  three  inches 
from  its  origin. 

The  nerves  of  the  diaphragm  are  the 
phrenic  and  phrenic  plexus  of  the  sympa- 
thetic. 

The  phrenic  nerve  arises  from  the  fourth, 
fifth  and  sixth  cervical  nerves.  In  man 
the  diaphragm  receives  a  sympathetic 
branch  from  the  inferior  cervical  ganglia, 
also  a  sympathetic  branch  from  the  ab- 
dominal brain  along  the  phrenic  arteries 
— the' phrenic  plexus. 

The  diaphragm  is  composed  of  lym- 
phatics and  spaces. 

Recklinghausen  was  first  to  show  the 
importance  of  lymphatic  system  in  dia- 
phragm. Ludwig  vSchweigger-Seidel  and 
Klein  perfected  his  work. 

Diaphragmatic  lymph  vessels  contain 
deposits  of  colored  granules,  but  the  lymph 
glands  and  viscera  do  not. 

Von  Recklinghausen,  i86t,  and  Pia 
Foa  and  Radjewsky  showed  that  fluids 
injected  into  the  peritoneum  would  pass 
through  the  serosa  of  the  centrum  ten- 
dineum, and  become  deposited  in  the  lym- 
phatics of  the  diaphragm. 

Bizzozero,  Salvioli  and  Muscalello 
showed  that  the  diaphragmatic  serosa  was 
capable  of  absorbing  solid  material. 


HIHLIOGRAPHY. 


Clauder,  G.  Ad  doct  marcuni  rujscli  df  ob- 
servatione  practico-anat  oniico  mirabili  ei)i>tela, 
Patavii,  i66r. 

liartholinus,  C.  Diaphrapmatis  sti  ujima  nova. 
Acta  med.  et  phil.     Hafn,  1676,  iv,  14-16'  2  pi. 


76 


SURGER2-  OF  THE  DIAPHRAGM. 


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phragm. Phil,  tr.,  London,  1719  33,  vi-vii,  683- 
687,  I  pi. 

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Senac.  Sur  le  diaphragme  (From  memacad 
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Senac.  Memoire  sur  le  diaphragme.  Hist. 
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Mem.  163-187,  I  pi. 

Haller,  A.  De  musculis  diaphragmatis,  Ber- 
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Louiche-Desfontaines,  R.  An  praecipnum 
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1781. 

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SURGERT  OF  THE  DIAPHRAGM. 


77 


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ANOMALIES     (1757-I9O3.) 

Anomalies  of  the  diaphragm  are  com- 
mon. The  diaphragm  may  be  absent  in 
man  in  part  or  in  its  entirety. 

The  attachments  may  be  higher  or  lower 
than  normal,  and  its  thickness  vary  greatly. 
It  may  have  one  or  more  fissures  varying 
in  size,  shape  and  location. 

The  openings  in  the  diaphragm  through 
which  the  esophagus  and  larger  blood- 
vessels pass  vary  considerably  as  to  loca- 
tion and  size.  The  number  and  distribu- 
tion of  the  phrenic  nerves,  lymphatics  and 
smaller  blood-vessels  may  also  vary. 

Historical. — De  Galatigny,  1757,  men- 
tioned a  case  in  which  he  observed  a  sin- 
gular displacement  of  the  diaphragm. 

Lawrence,  1S52,  noted  a  congenital  de- 
ficiency of  the  muscular  fibres  in  the  left 
half  of  the  diaphragm,  with  displacement 
of  the  stomach  and  double  pneimionia. 

liereaud,  1852,  noted  atrophy  of  the 
diaphragm  and  its  corresponding  tissues. 

Wood,  1855,  reports  a  case  of  malfor- 
mation of  the  diaphragm  and  displace- 
ment of  organs. 


McClintock,  1857,  records  a  case  of  con- 
genital perforation  of  the  diaphragm. 

Robinson,  1S60,  had  a  case  of  congenital 
deficiency  of  the  diaphragm,  with  malpo- 
sition of  the  viscera. 

John,  1867,  reported  a  case  of  ectopia 
of  the  diaphragin. 

ISIarsh,  1867,  reports  an  abnormal  con- 
dition of  the  diaphragm. 

Van  Gieson,  1871,  reports  a  case  of  par- 
tial deficiency  of  the  diaphragm  in  a  still- 
born infant. 

Tigri,  1873,  speaks  of  an  anomalous 
conformation  of  the  diaphragm. 

Raven,  1878,  reports  his  notes  of  a  case 
of  arrested  development  of  the  diaphragm. 

Caruthers,  1879,  recorded  a  similar 
case. 

I*olialon,  1881,  records  a  case  in  which 
there  was  congenital  absence  of  the  dia- 
phragm. 

Clarke,  1883,  and  Livingston  of  the 
same  year,  each  record  a  case  of  congenital 
deformity  of  the  diaphragm. 

Ledouble,  1883,  contributed  a  history 
of  the  anomalies  of  the  muscular  dia- 
phragm. 

Bernabei,  1884,  records  an  anomalous 
conformation  of  the  diaphragm. 

De  Schweinitz,  1888,  reports  a  case  in 
which  there  was  an  anomalous  arrange- 
ment of  the  right  diaphragmatic  leaflet. 

Paget,  1891,  reports  a  case  of  deficiency 
in  one-half  of  the  diaphragm. 

Guinard,  1891,  reports  his  observations 
on  the  development  and  anomalies  of  the 
diaphragm  of  animals,  especially  the  ox. 

Fry,  1895,  records  a  case  of  congenital 
defect  of  the  diaphragm  with  combined 
diaphragmatic  hernia. 

BinLIOGKAPlIY. 

De  Galatigny.  Rec.  period  d'obs.  de  med.  de 
chir.  et  pharm.,  Paris,  1757,  vii,  38  41. 

Pezzi,  P.  Di  alcuni  vizj  precordial!  congiunti 
aid  altri  esterni  disordini.  Gior.  per  serv.  ai 
progr.  d.  patol.,  Venezia,  1836,  iv,  274  302. 

Lawrence.     Lancet,  London,  1852,  ii,  327. 

Bereaud.  Conipt.  rend.  soc.  de  biol.,  1852, 
Paris,  1853,  iv,  5. 

Wood,  S.  N.  Y.  Med.  Times,  1S55,  iv,  120-122. 

McClintock.  Dublin  IIosp.  Gazette,  1857,  ns. 
iv, 138. 

Robinson,  T.  British  Med.  Journal,  1850,  ii, 
854856. 

Jahn,  L.     Deutsche  klinik.,  Berlin,  1867,  xix, 

325- 

Marsh,  F.  H.     Lancet,  London,  1867,  i,  298. 

Van  Geison,  R.  E.  Med.  Record,  New  York, 
1871,  vi,  427. 

Polailon.  Ann.  de  gynec,  Paris,  1881,  xiv, 
267-275. 


78 


SURGERT  OF  THE  DIAPHRAGM. 


Clarke,  W.  B,  British  Med.  Journal,  London, 
1882,  ii,  1086. 

Livingston,  B.  Am.  Jour.  Obst.,  New  York, 
1882,  XV,  'Jzy'JzS. 

Ledouble,  A.  Bull.  soc.  d.  (anthropol.)  de 
Paris,  18S3.  vi,  835-S,  847. 

Bernabei,  C.  Bull.  d.  soc.  tra  i  cult.  d.  sc. 
nied.  in  Sienna,  1884,  ii,  146  148. 

De  Schweinitz.  G.  E  Leonard's  Illustrated 
Med.  Journal,  Detroit,  1888,  ix,  53. 

Tigri,  A.  Arch,  di  med.  chir.  ed.,  ig.,  Roma, 
1873,  ix, 164-169. 

Longworth.    Clinic,  Cincinnati,  1877,  xii,  279. 

Raven,  T.  J.  British  Med.  Journal,  London, 
1878,  Ii,  796. 

Caruthers,  H.  Lt.  C.     Lancet,  London,  1879, 

i.  503- 

Paget,  Sir  J.     London,  1891,  149  151. 

Guinard.  Mem.  et  compt.  rend.  soc.  d.  sc. 
de  Lyon,  (1890),  i88r,  xxx,  pt.  2,  130  135. 

Guttniann,  P.  Angeborener  defect  in  der 
linken  zwerchfellshalfte  niit  hindurchtritt  dcs 
grossen  netzes  in  die  linke  pleurahohle.  Ver- 
handl.  d.  Berl,  med  gesellsch.  (1892),  1893,  xxii, 
pt.  2,  235  239. 

Fry,  F.  Montreal  Med.  Journal,  1895-6,  xxiv, 
101-105. 

SURGKUY      (1S6S-1897.) 

Surgical  operations  upon  the  diaphragm 
for  any  purpose  have  been  exceedingly 
limited.  No  doubt  many  interesting  cases 
in  which  surgery  has  been  applied  in  vari- 
ous degrees  have  not  been  reported. 

The  most  common  injuries  are  gun-shot 
and  stab  wounds. 

There  does  not  seein  to  have  been  any 
cases  reported  in  which  any  of  the  benign 
or  malignant  growths  have  been  removed. 

Cysts,  due  to  parasites,  tuberculosis, 
gangrene,  or  otherwise,  have  also  escaped 
surgical  intervention. 

However,  abscesses,  lacerated  and  pene- 
trating wounds  of  the  diaphragm  from 
any  cause  have  been  more  or  less  success- 
fully dealt  with,  surgically  in  a  few  cases. 

Hernia  of  the  abdominal  viscera  through 
the  diaphragm  into  the  thoracic  cavity  is 
probably  the  most  frequent  condition  re- 
quiring surgical  interference,  and  one  in 
which  the  least  has  been  done.  Great  care 
should  be  exercised  in  dealing  with  all 
injuries  of  the  body,  that  hernia  of  the 
diaphragm  may  not  be  overlooked,  espe- 
cially in  gunshot  and  stab  wounds,  blows 
upon  the  chest  and  abdomen,  and  falling 
from  a  loft. 

When  any  condition  requiring  surgical 
intervention  is  known  no  hesitation  should 
be  had  in  applying  the  same  surgical  prin- 
ciples to  the  diaphragm  as  are  applied  to 
the  other  tissues  of  the  body. 

l^epair  of  the  diaphragm  is  as  certain 
as  repair  of  other  tissues,  and  plastic  oper- 


ations of  the  diaphragm  in  the  more  highly 
organized  mammalia  can  be  made  as  cer- 
tain in  their  beneficial  results. 

Drainage  in  a  certain  class  of  surgical 
operations  upon  the  diaphragm  must  be 
provided  for  anteriorally  or  posteriorally 
through  the  abdominal  or  thoracic  cavity. 

Catgut  is  the  most  desirable  material 
for  suturing  the  diaphragm.  Exploration 
of  the  diaphragm  in  cases  of  doubtful 
involvement  of  it  should  not  be  neglected. 

There  are  no  doubt  many  cases  of  hernia 
of  the  diaphragm  that  are  never  recog- 
nized, except  post-mortem.  Many  of  them 
do  not  result  in  immediate  death,  but 
remain  to  cause  more  or  less  trouble  months 
or  years  afterward. 

Ricketts,  Girard  R.,  1S6S,  had  a  case 
in  which  a  circular  saw  cutting  from  be- 
hind divided  all  of  the  ribs  on  the  right 
side  near  their  spinal  attachment.  The 
lung  and  liver  were  extensively  lacerated, 
also  the  right  leaf  of  the  diaphragm.  Deep 
and  superficial  sutures  (sixty-nine  in  num- 
ber) were  utilized  in  closing  the  various 
tissues.  Drainage  was  established  and 
the  patient  (a  man,  Agustus  Fuller, 
twenty-five  years  of  age)  recovered.  He 
is  living.  May  20,  1903. 

But  few  surgical  operations  of  any  char- 
acter have  been  made  on  the  diaphragm 
for  any  cause. 

Despress,  1S69,  contributed  his  study  on 
the  surgical  pathology  of  the  diaphragm, 
and  Delahaussr,  1S85,  on  its  surgical  mala- 
dies. 

Lagrange,  1SS6,  notes  an  operation  for 
empyema,  which  involved  the  diaphragm. 

De  Nicola,  1S91 ,  refers  to  a  case  in  which 
he  sutured  the  diaphragm. 

Rydgier,  1S92,  reports  a  case  in  which 
he  had  performed  quite  an  extensive  oper- 
ation upon  the  diaphragm. 

Parlavecchio,  1893.  reported  a  surgical 
operation  in  which  he  sutured  an  injury 
of  the  diaphragm. 

Borsuk,  1893,  speaks  of  the  operative 
technique  of  wounds  of  the  diaphragm. 

Rossini,  1894,  reports  a  case  in  which 
he  applied  sutures  to  a  wound  of  the 
diaphragm. 

Ballerini,  1894,  mentions  a  case  of  in- 
jury of  the  diaphragm,  which  was  treated 
by  suture. 

Postemski,  1894,  made  a  surgical  oper- 
ation on  the  diaphragm. 

Schlatter,  1895,  mentions  a  case  of  sur- 
gery for  rupture  of  the  diaphragm. 


SURGER2'  OF  THE  DIAPHRAGM. 


79 


Tartauez,  1897,  prepared  an  elaborate 
treatise  on  the  intervention  in  abscess, 
cysta,  empyemas  and  subphrenic  abscess. 

UIKLIOGRAPIIY. 

Despress,  A.  N.  diet,  de  med.  et  chir.  prat., 
Paris,  1869,  xi,  360  374. 

Delahousse,  A.     Paris,  1S85. 

Lagfrange,  F.  Arch.  gen.  de  med.,  Paris,  1886, 
ii,  299  314. 

De  Nicola.  Postempski.  Bull,  de  soc.  med. 
Lanciasiana  d.  osp.  di   Roma    (1889-90),  1891,  x, 

151- 

Rydygier.     Wien.    klin.    Woch.,   1892,  v,  713- 

715- 

Parlavecchio,  G.  Postempski.  Rydygier  modi- 
ficati,  Riforma  med.,  Napoli,  1893,  ix,  pt.  2,  146- 

151- 

Borsuk,   M.     Medycyna  Watzawa,   1893,   xxi, 

337340- 

Severeano,  C.  D.  Considerations  sur  les  plaies 
du  diaphragma  par  la  voie  theracique.  Assoc, 
franc,  de  chir.,  Proc.  verb.,  Paris,  1893,  vii,  488- 
499- 

Rossini,  L.  Bull.  d.  sc.  Lancisiana  d.  osp.  di 
Roma,  1894,  xiii,  fasc.  2,  136. 

Ballerini,  E.  Bull.  d.  soc.  Lancisiana  d.  osp. 
di  Roma,  1894,  fasp.  2,  134. 

Saraiva,  L.  Bull.  d.  soc.  Lancisiana  d.  osp. 
di  Roma,  1894,  xiii,  fasc.  2,  137. 

Postemski  C.  Atti  di  xi  Cong.  med.  internaz., 
1894,  Roma,  1895,  iv,  Chir  ,  175-188. 

Schlatter,  C.  Corr.  bl.  f.  schweiz.  aerzte, 
Basel,  1895.  XXV,  353  358. 

Tartavez,  H.     Lyon,  1897. 

RUPTURE, 

Rupture  of  the  diaphragm  may  result 
from  injury  or  disease  without  causing 
serious  trouble. 

It  may  result  from  injury  without  frac- 
ture of  the  bony  structures  in  the  chest  or 
external  manifestations,  and  may  be  single 
or  multiple,  with  or  without  hemorrhage 
or  hernia  of  either  the  thoracic  or  abdom- 
inal viscera. 

Recovery  may  ensue  with  or  without 
surgical  intervention. 

Jlistorical . — Peyerus,  J,  C,  1685,  re- 
ports a  rupture  of  the  diaphragm. 

Fethergill,  J.,  1743-50,  describes  the 
case  of  a  female  child  ten  months  old,  in 
which  there  was  a  cleaving  of  the  dia- 
phragm and  the  situation  of  the  viscera 
altered. 

Godefroy,  1801,  reports  a  case  of  rup- 
ture of  the  diaphragm,  including  the 
stomach  and  the  arch  of  the  colon. 

Cavalier,  L.  J.,  1805,  mentions  several 
different  lesions,  and  a  case  of  hernia  in 
particular. 

Coutelle,  1819,  reports  a  case  of  rupture 
of  the  attachments  of  the  diaphragm,  and 
the  accompanying  reflex  disturbances. 


Davat,  1834,  published  his  memoirs  on 
the  rupture  of  the  diaphragm,  and  some 
of  the  grave  questions  involving  the  medi- 
co-legal aspects. 

Taylor,  1838,  mentions  a  recovery  after 
extensive  rupture  of  the  diaphragm, 

Dumas,  1841,  reports,  in  a  general  way, 
several  ruptures  of  the  diaphragm, 

Verriest,  J.,  1844,  gives  his  observations 
on  rupture  of  the  diaphragm,  including 
hernia  of  the  abdominal  viscera. 

Morehead,  C,  1844,  reports  a  case  of 
ruture  of  the  diaphragm,  sanguineous  effu- 
sion into  the  left  pleura,  and  into  the 
abdomen  a  strip  of  the  mucous  coat  of 
the  stomach,  lacerated  from  the  subjacent 
tunics, 

Williams,  C.  J.  B,,  1846-8,  reports  a 
rupture  of  the  esophagus  and  diaphragm 
induced  by  violent  vomiting. 

In  the  Medical  Times  and  Gazette,  of 
London,  is  mentioned  a  case  of  rupture 
of  the  diaphragm  associated  with  ventral 
hernia  (1850). 

Bigelow,  H.  J.,  1856,  describes  a  rup- 
ture of  the  diaphragm,  with  hernia  and 
fracture  of  certain  viscera. 

Murchison,  1862,  mentions  an  unusual 
case  of  rupture  of  the  diaphragm,  accom- 
panied by  displacement  of  liver  and 
stomach  into  left  pleura,  with  rupture 
of  stomach  and  left  kidney  and  fracture 
of  leg.  He  reports  another  case,  1866, 
where  there  was  displacement  of  liver  into 
right  pleura. 

Aman,  1869,  speaks  of  a  fatal  rupture 
of  the  diaphragm  ;  autopsy  revealed  eccen- 
tric alvi. 

Minor,  T,  T.,  1873,  had  a  case  of  double 
diphragmatic  rupture  and  hernia. 

Puzey,  1877,  reports  a  rupture  of  the 
diaphragm  with  hernia  of  stomach  and 
transverse  colon,  and  impacted  fracture  of 
neck  of  the  femur,  death,  Drepres  men- 
tions a  similar  case  (1879), 

Desir  de  Fortunet,  H.,  1887,  mentions 
a  rupture  of  the  diaphragm  with  fracture 
of  the  cartilage. 

Leighton,  1888,  describes  a  case  of  rup- 
tured diaphragm  and  death  by  apnea,  the 
stomach  and  spleen  occupying  the  left 
thorax. 

Clark,  1891,  had  a  case  of  rupture  of 
the  diaphragm  at  the  anterior  superior 
dependent  angle  of  the  esophagus  orifice, 
with  consequent  laceration  of  that  branch 
of  the  phrenic  artery  which  passes  through 
the    diaphragm    at    the    point,    and    dis- 


8o 


SURGERl'  OF  THE  DIAPHRAGM. 


turbance  of  the  accompanying  phrenic 
nerves. 

Warner,  1S91,  reports  a  rupture  of  the 
diaphragm. 

Manara,  1S94,  mentions  a  rupture  of  the 
diaphragm  with  hernia  of  the  stomach. 

()mboni,  N.,  1S94,  describes  a  case  in 
which  there  was  a  ruptured  diaphragm, 
accompanied  by  displacement  of  stomach 
and  colon  into  the  pleural  cavity. 

Czernicki,  189^,  had  a  case  of  rupture 
of  the  diapliragm  into  the  thoracic  cavity, 
followed  by  hernia  of  the  stomach. 

Kilgore,  1S97,  describes  a  case  in  which 
the  stomach  protruded  through  a  laceration 
in  the  diaphragm. 

lUIiLIOGRAPHV. 

Peyerus,  J.  C.  Misc.  acad.  nat.  curios.,  1685; 
Noriinb.,  1705,  iv,  decuria,  2,  195. 

Fethergill,  J.  Philadelphia  Tr.,  London, 
1743-50.  xi,  1077-10.S3. 

Godefroy.  Jour.de  Med.Chir.  Pharm.,  Paris, 
1801,  1,339-343- 

Cavalier,  L.  J.     Paris  an.,  xiii,  1805. 

Coutelle.  Jour.  gen.  demed.  Chir.  et.  Pharm., 
Paris,  1819,  Ixvi,  305  314. 

Davat.     Arch.  gen.  de  Med.,  Paris,  1834,  2s, 

vi,  32  54- 

Taylor,  H.  S.  Guy's  Uosp.  Report,  London, 
183S,   iii,  366-369. 

Dumas.  Jour.  Soc.  de  Med  prat,  de  Montpel., 
i8|.i,  iv,  10-22. 

Cases.     Lancet,  London,  1842-43,  ij,  702. 

Verriest,  J.  Ann.  Soc.  ISIed.-Chir.  de  Bruges, 
1844,  V,  ?40-246. 

Morehead,  C.  Tr.  Med.  and  Phys.  Soc,  Bom- 
bay, 1844,  vii,  loi. 

Williams.  C.  J.  B.  Tr.  Path.  Soc,  London, 
1846-8,  i,  151.  Med.  Times  and  Gaz.,  London, 
1850,  xxi,  314. 

Bigelow,  H.  J.     Extra  Rec,  Boston  Soc.  M. 
Improv.  (i8t;4-^),  i8s6,  ii,  291. 
F    ^    ^ 

Murchison.  Tr.  Path.  Soc,  London,  1861  2, 
xiii,  70. 

Murchison.  Tr.  Path.  Soc,  London,  1865  6, 
xvii,  164. 

Aman.  P'orh.  svens.  lak-sallak  sammank, 
Stockholm,  1869,  72  74. 

Minor,  T.  T  Rep.  Superv.  Surg.  Mar.  Hosp., 
Washington,  1873,  115  119,  i  pi. 

Minnich.     Wien.  Med.  l^resse,  1875,  x^'>  57  59- 

Puzey,  C.     Lancet,  London,  1877,  ii,  571. 

Despres.     Paris  Med.,  1879,  2s,  v,  73. 

Stunipf,  J.     Wurzburg,  1879. 

Desir  de  Fortunet,  H.  Mem.  etCompt.  Rend. 
Soc.  d.  Sc,  Med.  de  Lyon  (1886),  1887,  xxvi, 
218-226. 

Utz.     Thierarztl.  niitth.,  Karlsruhe,  1887,  xxii, 

"3-"5- 

Leighton,  N.  W.  Gaillard's  Med.  Journal, 
1888,  xlvii  (xlvi),  3  9-321. 

Clark,  S  T.  Tr.  New  York  Med.  Ass'n.,  1891, 
viii,  285  288. 

Werner.  Berlin  thierarztl.  Woch.,  1891,  vii,  49. 

Manara,  ().  Bull.  d.  Soc.  Lancisiana  d.  Osp. 
di  Roma,  1894,  xiii,  fasc.  2,  138. 


Omboni,  V.    Gazz.  Med.  cremonese,  Cremona, 

1894,  ''''^»  ^4"i30- 

Czernicki.  Arch,  de  Med.  et.  Pharm.  Mil  , 
Paris,  1894,  xxiv,  39^  399 

Kilgore,  F.  D.  Univ.  Med.  Mag.,  Philadel- 
phia, 1896  97,  ix,  349. 

INJURIES    AND    LACERATIONS. 

Injuries  of  the  diaphragm,  such  as  lacer- 
ations, perforations,  and  contusions,  are 
frequent  and  of  many  varieties,  depending 
upon  the  character  of  the  instrument. 
They  may  result  from  injury  without  frac- 
ture of  the  bony  chest  or  evidence  of  ex- 
ternal violence. 

Hemorrhage  may  be  mild  or  severe,  and 
escape  into  the  thoracic  or  abdominal 
cavity,  or  both. 

Laceration  of  the  diaphragm  is  supposed 
to  occur  more  frequently  from  a  blow  upon 
the  chest  or  abdomen,  or  falling  from  a 
loft,  while  the  lungs  are  at  their  maximum 
distention. 

Destruction  of  one  or  all  of  the  phrenic 
nerves  or  blood-vessels  does  not  interfere 
with  respiration. 

Historical. — Halle,  1804,  made  obser- 
vations on  perforating  ulcers  of  the  dia- 
phragm. 

Lorey,  1808,  made  observations  in  a  case 
which  had  received  injuries  in  the  head 
causing  perforation  of  the  diaphragm  and 
the  stomach. 

Wheelwright,  1819,  reports  a  lacerated 
diaphragm  from  external  violence,  without 
fracture  of  the  ribs. 

Wood,  1824,  had  a  case  which  recov- 
ered from  a  punctured  wound  of  the  dia- 
phragm. 

Raphael,  1841,  reports  the  case  of  a 
patient  falling  from  the  fourth  story  caus- 
ing fracture  of  the  ribs,  laceration  of  the 
liver,  diaphragm  and  pericardium,  with 
singular  displacement  of  the  stomach. 

Banks,  1848,  reports  an  extensive  lacer- 
ation of  the  liver  and  diaphragm  from  the 
kick  of  a  horse. 

Vogler,  1854,  describes  a  penetrating 
wound  of  the  diaphragm. 

Bonamy,  1858,  made  observations  of 
the  ulceration  and  perforation  of  the  dia- 
phragm with  eruption  in  the  peritoneum 
and  bronchi. 

Solly,  1867,  reports  on  injuries  of  the 
diaphragm,  illustrated  by  a  case  in  which 
there  were  all  the  symptoms  of  lacera- 
tion of  that  muscle,  but  the  patient  re- 
covered. 

Henwood,  1868,  describes  an  extensive 


SURGERT  OF  THE  DIAPHRAGM. 


8i 


laceration  of  the  diaphragm,  with  protru- 
sion of  the  great  curvature  of  the  stomach 
into  the  right  pleural  cavity. 

De  Morgan,  1S73,  reports  a  perforation 
of  the  diaphragm  by  a  fractured  rib,  with 
wound  of  the  bowel  and  spleen. 

Chamousset,  1875,  mentions  a  case  of 
acute  pleurisy  followed  by  perforation  of 
the  diaphragm,  death. 

Gerard  -  Marchant,  1900,  describes  a 
penetrating  wound  of  the  diaphragm  with 
rupture  of  the  liver.  The  diaphragm  was 
sutured,  patient  recovered. 

BIBLIOGRAPHY. 

Halle.  Bull.  Fac.  de  Med.  de  Paris,  1804-12, 
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HKRNIA     (aCQJJIRED,   CONGENITAL), 
( I 700-1 903). 

Hernia  of  thoracic  or  abdominal  viscera 
through  the  diaphragm,  may  result  from 
congenital  defects,  disease  or  injury. 

It  may  exist  indefinitely  without  causing 
serious  trouble  in  any  way  whatever ;  in- 
deed, their  presence  may  never  be  detected 
except  by  autopsy. 


Obstruction  and  gangrene  are  two  of 
the  most  common  complications. 

Historical . — Holt,  C.,  1700,  describes 
hernia  of  the  diaphragm  in  a  child  with  the 
intestines  and  other  viscera  in  the  thorax. 

Loder,  1784,  and  Derrecagaix,  1792, 
each  mention  hernia  of  the  diaphragm. 

Spry,  1801,  observed  a  hernia  of  the 
stomach  through  the  tendinous  orifice  of 
the  diaphragm  in  a  domesticated  cat. 

Reynaud,  1S13.  made  some  observations 
on  hernia  of  the  stomach,  colon  and  part 
of  the  duodenum  through  the  diaphragm. 

Lerminier,  182 1,  describes  a  case  of 
strangulated  hernia  of  the  stomach  through 
the  diaphragm. 

Cornell,  1825,  reports  a  case  of  hernia 
of  the  diaphragm,  with  the  escape  of  all 
the  intestines  through  the  diaphragm  into 
the  right  side  of  »he  thorax. 

Hunt,  1827,  mentions  hernia  of  the 
stomach  through  the  diaphragm. 

Fehleisen,  1828,  made  observations  on 
hernia  of  the  diaphragm  in  a  horse. 

J^erndt,  1829,  reports  a  case  of  hernia 
of  the  diaphragm  penetrating  the  thoracic 
cavity. 

Larussac,  1831,  describes  a  strangulated 
hernia  formed  by  part  of  the  transverse 
colon  passing  through  an  opening  in  the 
diaphragm. 

Cases,  1831,  and  Caultier  de  Claubry, 
1834,  each  make  mention  of  hernia  of  the 
diaphragm. 

Hughes,  1837,  describes  a  hernia  of  the 
diaphragm  caused  by  a  blow  on  the  side, 
followed  by  peritonitis,  the  ulcerated  bowel 
breaking  through  the  diaphragm,  resulting 
in  gangrene  of  the  lungs. 

Curling,  J.  B.,  1837,  mentions  a  hernia 
of  the  diaphragm.  Tliere  was  extensive 
laceration  of  diaphragm  with  the  escape 
of  a  great  part  of  the  abdominal  viscera 
into  the  left  cavity  of  the  chest. 

Da  Silva,  J.  T.,  1840,  made  observations 
on  hernia  of  the  diaphragm  penetrating 
the  thoracic  cavity,  with  fracture  of  the 
humerus. 

Auzelly,  1842,  made  a  report  on  the 
symptoms,  character  and  anatomy  of  her- 
nia of  the  diaphragm. 

Williamson,  1848,  contributed  an  inter- 
esting article  on  the  wounds  of  the  dia- 
phragm followed  by  hernia  of  the  stomach 
and  colon. 

Tvlartus,  1849,  mentions  a  singular  case 
of  strangulated  hernia  of  the  diaphragm. 

Sallion   (pare),  1S50,  reports  a  case  of 


82 


SURGERT  OF  THE  DIAPHRAGM. 


hernia  of  the  diaphragm  through  the 
stomach,  spleen  and  colon, 

Valette,  1852,  had  a  case  of  perforated 
diaphragm  with  hernia  and  rupture  of  the 
stomach. 

Bowditch,  H.  I.,  1853,  wrote  a  treatise 
on  diaphragmatic  hernia,  being  an  account 
of  a  case  observed  at  the  Massachusetts 
General  Hospital,  followed  by  a  numerical 
analysis  of  all  the  cases  of  this  alTection 
found  recorded  in  the  writings  of  medi- 
cal authors  between  the  years  1600  and 
1846. 

Beck,  1854,  mentions  a  hernia  of  the 
diaphragm,  the  stomach,  spleen,  omentum 
and  a  portion  of  the  colon  found  in  the 
left  pleural  cavity. 

Jackson,  1858,  reports  a  case  of  hernia 
of  the  diaphragm  with  the  protrusion  of 
the  abdominal  viscera  into  the  chest; 
death,  autopsy, 

Alderson,  1858,  describes  a  diaphrag- 
matic hernia  with  symptoms  of  pneumo- 
thorax, the  stomach,  spleen,  omentum  and 
transverse  colon  lying  in  the  left  pleura, 
resulting  in  death. 

Herchon,  1861,  reports  a  case  of  hernia 
of  the  diaphragm  in  a  suicide;  autopsy 
revealed  double  penetration  of  the  dia- 
phragm, with  the  spleen  rupturing  into 
the  thoracic  cavity. 

Gallois,  1867,  mentions  a  case  of  hernia 
of  the  diaphragm  causing  displacement 
of  the  heart  and  stomach. 

Hammer,  186S,  had  a  case  of  strangu- 
lation of  the  transverse  colon  caused  b}'  a 
diaphragmatic  hernia;   death. 

Hill.  1870,  mentions  -a  true  diaphrag- 
matic hernia,  with  stricture  of  the  eso- 
phagus, 

Vezien,  1871,  describes  a  diaphragmatic 
hernia  penetrating  the  thoracic  cavity, 

ISIuller,  1 87 1,  reports  a  case  of  diaphrag- 
matic hernia  displacing  the  heart,  death 
from  uremia  consequent  on  granular  de- 
generation of  the  kidneys, 

Minor,  1S73,  mentions  a  case  of  double 
diaphragmatic  hernia  penetrating  the 
pleural  cavity. 

Cameron,  1874,  a  case  of  fracture  of  the 
femur  with  hernia  of  the  diaphragm,  a 
knuckle  of  the  liver  strangulated;  death. 

Cartier,  1876,  made  observation  on  her- 
nia of  the  diaphragm  with  a  great  part 
of  the  abdominal  viscera  penetrating  the 
thoracic  cavity. 

Foster,  1S76,  reports  a  diaphragmatic 
hernia    with    protrusion    of  stomach   into 


thorax,  rupture  of  liver,  iliac  veins  and 
jejunum. 

Macnah,  1878,  reports  a  case  of  dia- 
phragmatic hernia  of  the  entire  stomach 
three  years  after  the  cure  of  empyema. 

Dean,  1884,  mentions  a  case  of  diaphrag- 
matic hernia  of  the  stomach. 

Kough,  1884,  describes  Bufl'er  accident, 
necropsy  revealing  two  ruptures  of  the 
diaphragm  and  protrusion  of  the  right 
lobe  of  the  liver,  the  spleen,  and  the 
stomach  into  the  thoracic  cavity,  with 
laceration  of  spleen  and  kidneys. 

Flaherty,  1903,  describes  a  case  of  dia- 
phragmatic hernia  following  penetrating 
wound  of  the  thorax. 

Erdt,  1902,  mentions  a  case  of  diaphrag- 
matic hernia  with  stomach  and  intestines 
rupturing  into  the  thoracic  cavity ;  death 
on  the  fourth  day  after  accident. 

CONGEXITAL    HERNIA. 

Benjumeda,  1S25,  was  among  the  first 
to  make  observations  on  congenital  hernia 
of  the  diaphragm. 

Anthony  and  Forget,  1835,  report  a 
congenital  hernia  of  the  diaphragm,  with 
rupture  of  the  abdominal  viscera. 

Hillier,  i860,  reports  a  congenital  her- 
ni.i  allowing  nearly  all  of  the  small  intes- 
tines and  two-thirds  of  the  large  to  pass 
into  the  right  side  of  the  thorax. 

Pozzi,  1874,  mentions  a  congenital  her- 
nia of  the  diaphragm,  with  displacement 
of  the  greater  part  of  abdominal  viscera, 
including  the  heart. 

Smith,  1874,  reports  a  fetus  with  a  dia- 
phragmatic hernia. 

Davis,  1884,  describes  a  singular  case 
of  congenital  malformation  of  the  bowels, 
intestines  in  the  chest,  in  an  adult. 

lilBLIOGRAPnY ACCyjIRED    HERNIA. 

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CONGENIT.\L    HERNIA. 

Benjumeda,  J.  Jour.  Univ.  d.  Sc.  Med.,  Paris, 
1825.  xxxix,  113-121. 

Anthony  and  Forget.  Jour.  Hebd.  d.  Progr. 
d.  Sc  et  Inst.  Med.,  Paris,  1835,  i,  225-231. 

von  Basedow.  Woch.  f.  d.  Ges.  Heilk.,  Berlin, 
1837,  466-471. 


SURGERT  OF  THE  DIAPHRAGM. 


85 


I 


Gadecheup,  B.  Zeitschr.  f.  d.  ges.  Med., 
Hamb.,  1838,  vii,  503  510. 

Scholler,  J.  Mag.  f.  d.  Ges.  Heilk.,  Berlin, 
1842,  lix,  437  461,  I  pi. 

Bloest.  Med.  cor.-bl.  Layer  aerzte,  Erlang  , 
18+6,  vii,  337,  353,  369 

Feiler.  Verhandl.  d  Gesellsch.  f.  Geburtsh. 
in  Berlin,  (18^6-7),  1858.  x,  32  37. 

Hillier,  T.'  Tr.  Path.  Soc.,  London,  i860, 
1861,  xii,  115,  117. 

Balfour,  T.  A.  G.  Edinburgh  Med.  Journal, 
1868-9,  xiv,  883  914. 

Gruber,  W.  Arch.  f.  path,  anat.,  Berlin,  1869, 
xlvii,  382,  399,  2  pi. 

Lorge,  V.  Journal  d.  Med.  Chir.  et.  Pharm., 
Brussels,  1872,  Iv,  126129 

Pozzi,  S.  Bull.  Soc.  Anat.,  Paris,  1872,  1874, 
xlvii,  90  95. 

Smith,  H.  Tr.  Obst.  Soc,  London  (1873), 
1874,  XV,  162,  I  pi. 

Kohn,  R.     Congenita,  Erlangen,  1879. 

Cuervoy  et  Alvarez.  Cron.  med.  quir.  de  la 
Habana,  1879,  v,  54  57. 

Michener,  E.  Med.  and  Surg.  Reporter, 
Philadelphia,  1882,  xlvi,  138. 

Pohrovvki,  P.  A.  Russk.  Med.  Voskresensk., 
1883,  i,  13. 

Davis   G.  G.     Med.  Age,  Detroit,  1884,  ii,  60. 

Waldeyer.  Deutsche  Med.  Woch.,  Berlin, 
i88v,  X,  211. 

Dugeut,  J  B.  De  la  hernie  diaphragmatique 
congenitale,  Paris,  1886.   (The  same,  Paris,  1866.) 

ABSCESS  (1868  1901). 

Abscess  may  be  primary  or  secondary, 
usually  secondary,  and  about  the  posterior 
attachments  of  the  diaphragm. 

The  pus  usually  passes  into  the  pleural 
cavity  and  lung,  to  escape  through  the 
bronchus  or  along  the  psoas  muscle,  to  es- 
cape at  some  point  about  the  pelvis,  pre- 
ferably Poupart's  ligament. 

It  may  rupture  into  the  stomach  or  in- 
testinal tract,  peritoneal  cavity  or  at  some 
point  about  the  groin. 

Primary,  is  usually  due  to  infection 
of  various  kinds  of  cysts,  including  hema- 
toma. 

Secondary ,  when  infection  extends  from 
the  lung,  liver,  necrosed  ribs  or  vertebra;, 
or  disuse  of  adjacent  tissues  or  organs, 
such  as  the  biliary  tract,  appendix,  pan- 
creas, kidney  or  liver  from  any  cause. 

Historical. — Larcher,  1868,  records  a 
case  of  primary  serous  cyst  of  the  dia- 
phragm. 

Janeway,  1877,  reports  a  case  of  abscess 
of  the  diaphragm  and  distention  and  rup- 
ture of  the  bile-duct. 

Paetsch,  1S82,  operated  for  a  subphrenic 
abscess. 

White,  1890,  speaks  of  the  relation  of 
subdiaphragmatic  abscess  to  the  thoracic 
viscera,  with  three  illustrative  cases. 


Freiberg,  A.  H.,  1S97,  reported  a  case 
of  subphrenic  abscess  drained  posteriorly 
with  recovery  (Cincinnati  Academy  of 
Medicine). 

Ricketts,  E.  S.,  1897,  had  a  case  of  sub- 
phrenic abscess  complicated  with  rupture 
into  the  pleural  cavity.  Operation  ;  an- 
terior and  posterior  drainage;  recovery. 

Ricketts,  B.  ISIerrill,  had  two  cases  of 
subphrenic  abscess  from  appendicitis;  one 
(1898)  recovered  at  the  end  of  ten  weeks 
by  thorough  drainage  ;  the  other  died  after 
several  weeks  (1894). 

Dalbes,  1900,  contributed  to  the  study 
of  subphrenic  abscess. 

Godlee,  1900,  also  discussed  the  subject 
of  subphrenic  abscess. 

Baldwin,  1900,  records  two  cases  of 
subphrenic  abscess  following  appendicitis. 

Kohne,  1900,  records  a  case  of  subphre- 
nic abscess  with  pyopneumothorax,  in 
which  drainage  was  thoroughly  estab- 
lished. 

Sorel,  1900,  records  a  subphrenic  ab- 
scess rupturing  into  the  pericardium. 

Majewski,  1900,  contributed  a  paper  on 
the  diagnosis  of  diaphragmatic  cysts  of 
liquid  collections. 

Baron,  1900,  reports  one  case,  and  Berg, 
1900,  three  cases  of  subdiaphragmatic  ab- 
scess. 

Strajeska,  1901,  records  a  case,  and  Gas- 
ton, 1901,  one  in  which  there  were  many 
complications. 

Cheedle  and  Collier,  1901,  record  a  case 
of  subphrenic  abscess  complicated  with 
splenic  abscess,  with  recovery. 

Ramagoli,  1801,  reports  a  subphrenic 
abscess,  and  Thomas,  1901,  one  with  cal- 
cified walls,  discovered  during  conva- 
lescence from  typhoid  fever,  operated 
upon,  with  recovery. 

Areyzi,  1901,  reports  a  diaphragmatic 
abscess. 

Weber,  1901,  also  reports  such  a  case. 

Cambell  and  Wood,  1801,  had  such  a 
case  recover  from  operation. 

Ricketts,  B.  Alerrill,  1901,  had  a  case 
of  pulmonary  abscess  rupturing  through 
the  diaphragm,  passing  downward  behind 
the  peritoneum  into  the  pelvic  cavity, 
from  which  the  pus  escaped  through  an 
incision  to  reduce  a  femoral  hernia. 
Large  quantities  of  pus  escaped  through 
the  opening  for  several  months;  recovery 
otiierwise  uneventful.  (This  case  was 
under  the  care  of  Dr.  Corliss,  Brooksville, 
Ky.) 


86 


6"  URGER  r  OF  THE  DIA  PIIRA  GM. 


BIBLIOGRAPHY. 

Larcher,  O.     Arch.  gen.  de  med.,  Paris,  iS68, 
i,  283  288. 
Janeway.    N.  Y.  Journal  Medicine,  1877,  xxvi, 

531- 

Sanson.     Gaz.  d.  hop.,  Paris,  1832,  vi,  237. 

Paetsch.  Charite  Ann.,  Berlin,  1882,  vii, 
300  307. 

Bernabei,  C.  Boll.  d.  soc.  tra  i.  cult.  d.  sc. 
med,  in  Siena,  1884,  ii,  83-85. 

White,  J.  W.  British  Med.  Journal,  London, 
1890,  I,  1002- 1006. 

Faure.  (Neoplasme  ou  ulcere.)  Independ. 
med.,  Paris,  1900,  vi,  321. 

Lauwers.  Amm.  soc.  beige  de  chir.,  Brux, 
1900,  viii,  242-249,  I  fig. 

Dalbes,  E.  Toulouse  Imp.  G.  Berthoumien, 
1900,  No.  373,  62  p. 

Godlee,  R.J.  British  Med.  Journal,  London, 
1900,  ii,  996,  998,  999,  1000. 

Baldwin,  R.  J.     Cleveland  Med.  Journal,  1900, 

V,  337  341- 

Jonnesco,  Th.  Bull,  et  mem.  soc.  de  chir.  de 
Bucarest,  199,  ii,  130-132. 

Krohne,  O.  Deut.  med.  woch.,  Lpz.,  1900, 
xxvi,  708-711. 

Serel.  Languedoc  med.  chir.,  Toulouse,  1900, 
2s,  viii,  65-67. 

Baron,  J.     Pest.   med.  chir.  Presse,  Budapest, 

1900,  xxxvi,  481-484. 

Majewcki,  A.  Gaz.  lek.  Warszawa,  1900,  xx, 
214  218. 

Berg,  A.  A.  Med.  Record,  New  York,  1900, 
Ivii,  221-226,  2  fig. 

Romagnoli,  U.  Lucca  Lucca  Baroni,  1901, 
2ip. 

Strajeske,  N.  Vratch.,  St.  Petersb.,  1901, 
xxii,  737-739- 

Gaston,  J.  MoF.  Atlantlanto  Jour.  Rec.  Med., 

1901,  iii,  98-111. 

Cheadle  and  Collier.  Lancet,  London,  1901, 
I,  1079  1080. 

Thomas,  W.  T.  Liverpool  Med.  Chir.  Jour- 
nal, 1901,  xxi,  65-68. 

Arezzi,  F.   Riforma  med.,  Roma,  1901,  ii,  687. 

Weber,  J.  Ueut.  Ztschr.  f.  chir.,  Lpz.,  1901, 
Ix,  127-139. 

Campbell  and  Wood.  British  Med.  Journal, 
1901,  1,  697-698. 

Grunbaum,  A.  Trois  eas  d'absces  sous-phre- 
nique.     Gaz.   lek.   Warszawa,  1901,  xxi,  478-482. 

Darling,  E.  A.  Boston  Med.  and  Surg.  Jour- 
nal, July,  1902,  p  70. 

GANGRENE     (1835-I9O3). 

This  is  a  rare  condition,  and  when  pres- 
ent may  be  primary  or  secondary,  rarely 
primary,  and  generally  due  to  injury  or 
infection,  or  both. 

BIBLIOGRAPHY. 

Leguey.  Un  cas  de  foyer  gangreneux  dia- 
phragme.     Bll.  soc.  de  anat.,  Paris,  1855  6,  x,  40. 

Hertz,  H.  Ein  fall  von  gangran  der  lunge  des 
diaphragma's  und  der  milz.  Arch.  f.  path,  anat., 
Berlin,  1867,  xi.  580-586. 

Manussi.  Tuberculosis.  Resoc.  s.  d.  Osp.  Civ. 
di  Trieste  (i875(,  1877,  "U  186. 


NEOPLASMS. 

Neoplasms,  benign  or  malignant,  are 
infrequent.  The  cases  of  lipomata,  chon- 
dromata,  angiomata,  carcinomata,  sarco- 
mata and  ossification  are  exceedingly 
rare ;  also  cases  of  echinococcus  and  fun- 
gosities. 

LIPOMATA. 

D'ajutolo,  G.  Su  di  un  case  rare  di  ernia  dia- 
jramatica  lipomatosa  con  altre  particolarita 
anatomiche  nella  pleura  destra  e  nello  sfenoide. 
Bull.  d.  sc.  med.  di  Bologua,  1884,  6s,  xiv,  27-40, 
I  pi. 

Clark,  F.  W.  Subpleural  Lipoma  of  Dia- 
phragm. Tr.  Path.  Soc,  London,  (1886-7)  1887, 
xxxviii,  324. 

OSSIFICATION. 

Lefevre.  Fievre  grave  apoplexte  pulinonaire 
avec  hemorrhagic  exterieure  ossification  du  dia- 
phragme.     Gaz.  d.  hop.,  Paris,  1837,  xi,  473. 

Pagan,  J.  Curious  Case  of  Chronic  Pleuritis, 
with  Ossification  of  the  Diaphragm  and  Partial 
Aphonis-  India  Jour.  Med.  and  Phys.  Sc,  Cal- 
cutta, 1841,  ns.  vi.  665. 

Neil,  J.  Ossification  of  the  Tendon  of  the 
Diaphragme.  Am.  Jour.  Med.  Sc,  Philadelphia, 
1849,  ns.  xviii,  121. 

Guyon.  Concretion  ossiforme  trouvee  sur  la 
face  oonvexe  du  diaphragme.  Bull.  soc.  deanat., 
Paris,  1855,  XXX,  37. 

Brute.  Ossification  en  plaques  du  centre  phre- 
nique  du  diaphragm.  Bull.  soc.  de  anat.,  Paris, 
(1868),  1874,  xliii,  429. 

Garraud.  Note  sur  un  cas  d'ossification  du 
diaphragme.  Loire  med.,  Ss.  Etienne,  1888, 
vii.  34- 

ANGIOMATA. 

Texter,  K,  Beitrag  zur  saustik  der  angeboren 
zwerchfellebruche  Med.  cor  -  bl.  bayer  Aerzte 
Erlang,  1847,  viii,  317  324. 

Schranl,  J.  M.  Waarneming  eene  anngeborene 
middel-rifsbreuk  bij  een  15  jahrigen  jongen 
Nederl  Weekbl.  v  Geneesk.  Amst.,  1854,  '^^>  ^'3> 

Muller,  C.  D.  R.  Angeborener  zwerchfell- 
bruch  Marburg,  1856. 

Hoffmann,  K.  Angeborne  hernia  diaphrag- 
matica  Wien  med.  woch.,  1866,  xvi,  943. 

Froebelius.  Fall  von  angeborenen  partiellem 
zwerchfeldefect,  St.  Petersb.  med.  woch.,  1881, 
vi,  17. 

Abel,  K.  Ein  fall  von  angeborenen  links- 
seitigen  zwerchfellsdefect  mit  hindurchtritt  des 
magens  des  grossen  netzes  eines  theiles  des  colon 
un  des  duodenum  in  die  pleurahohle  Berl.  klin. 
woch.,  1894,  xxxi,  84-114. 

Hubl,  H.  Kind  mit  angeborenen  linksseitieem 
zwerchfeldefekt  Centrbl.  f.  gynakol.,  Lpz.,  1897. 
xxi,  1353. 

ECHINOCOCCUS. 

Wolff.  Fall  von  ecchinococcus  diaphraghrag- 
matis.  Deut.  mil-arztl.  Ztschr  ,  Berlin,  1882, 
xi,  231-334. 

Berger,  E.  Cisti  da  echinococco  della  cupola 
del  diaframma  asportazione  guarigione  Incura- 
bili.  Napoli,  1900,  xv,  449. 


SUIiGERl'  OF  THE  DIAPHRAGM. 


87 


FUNGOID. 

Grawcher.  Vegetations  Causing  Tumor  in  the 
Center  of  tbe  Diaphragm.  Bull.  soc.  nnat.,  Paris, 
(1868J,  1874,  xliii,  385, 

TUBERCULOSIS    OF    DIAPHRAGM. 

There  is  great  doubt  as  to  this  disease, 
when  present  in  the  diaphragm,  being 
primary. 

The  cases  of  any  form  of  tubercular 
disease  of  the  diaphragm  being  so  few, 
but  little  opportunity  has  been  given  for 
the  consideration  of  the  subject. 

It  seems  to  resist  attacks  in  all  forms  of 
pulmonary  tuberculosis. 

CARCINOMATA. 

Walters,  J.  Scirrhus  of  the  Diaphragm.  Tr. 
Path.  Soc,  London  (1876).  1877,  xxviii,  218. 

Smith,  W.  G.  Carcinoma  of  Diaphragm  and 
Peritoneum  and  Myoma  of  the  Uterus.  British 
Med.  Journal,  London,  i88r,  i,  17. 

SARCOMATA. 

Dalzell.  Primary  Sarcoma  of  Diaphragm 
with  Secondary  Deposits  in  Skull  and  Femur 
Leading  to  Fracture  of  the  Latter  Bone.  Glas. 
gow  Med.  Journal,  1887,  xxvii,  298-301. 


MISCELLANEOUS  BIBIOGRAPHY- 
(1689-I9OO.) 


DIAPHRAGM 


I 


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Ettmuller,  M.  E.  (Pr.)  de  diaphragmatis  vul- 
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Richter,  E.  E.  Von  einem  stich  mit  einem 
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NEURALGIA. 

Lewenhock,  A.  Palpitation  of  the  Diaphragm. 
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SURGER2'  OF  THE  DTAPHRACM. 


91 


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IV. — Surgery  of  the   Spleen. 


ANATOMY    AXD    PHYSIOLOGY 
(1652-I9O3). 

The  spleen  is  a  ductless  gland  situated 
immediately  at  the  tail  end  of  the  pan- 
creas. 

It  is  classified  with  the  thymus,  thyroid 
and  suprarenal  capsules.  It  is  an  oblong 
and  flattened  body,  situated  in  the  left 
hypochondriac  region,  behind  the  perito- 
neum. It  is  soft  and  brittle,  highly  vascu- 
lar, and  connected  with  the  stomach  to  the 
gastro-splenic  omentum,  which,  together 
with  two  folds  of  the  peritoneum,  hold  it 
in  position,  and  connect  it,  more  or  less, 
with  the  kidney,  and  sometimes  with  the 
diaphragm. 

Its  size  varies  with  different  individuals, 
and  under  different  circumstances  ;  in  adult 
life  it  weighs  from  five  to  eight  ounces, 
and  is  from  four  to  seven  inches  long  and 
from  two  to  four  inches  wide.  It  is  about 
the  same  size  at  time  of  birth,  not  increas- 
ing normally  with  the  growth  of  the  body. 
At  birth  its  weight  in  proportion  to  the 
entire  body  is  almost  equal  to  what  it  is 
in  the  adult,  being  i  to  350,  while  in  the 
adult  it  varies  from  i  to  320  and  400. 
In  old  age  it  decreases,  becoming  as  i 
to  700. 

It  becomes  larger  during  digestion,  is 
greatly  influenced  by  the  character  of  food, 
and  becomes  less  during  fasting. 

Various  fevers  cause  it  to  enlarge  to 
fifteen  or  more  pounds. 

It  has  an  external  serosa,  and  an  inter- 
nal fibrous  elastic  coat.  The  first  is  thin 
and  smooth.  The  splenic  artery  arising 
directly  from  the  abdominal  aorta  is  large, 
tortuous,  and  divided  into  four,  five  or  six 
branches,  which  enter  the  hilum  of  the 
spleen  and  ramify  throughout  its  substance, 
receiving  sheaths  from  an  involution  of 
the  external  fibrous  tissue. 


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SURGERY  OF  THE  SPLEEN. 


95 


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ABNORMALITIES    (1763-I9O3). 

The  spleen  is  subject  to  many  anoma- 
lies in  all  animals. 

There  may  be  one  or  more  spleens. 

They  may  be  located  in  any  part  of  the 
abdominal  cavity. 

Several  cases  are  recorded  in  which  the 
spleen  was  found  entirel}'^  absent.  This 
may  be  congenital,  or  due  to  destruction 
by  disease. 

When  absent  there  is  general  compensa- 
tory lymphatic  hyperplasia. 

Historical. — Nenci,  1763,  mentions  a 
case  of  disruptured  spleen,  while  Aber- 
nethy,  i79;^>  gives  an  account  of  two  in- 
stances of  uncommon  formation  of  the 
spleen  in  the  human  body. 

Fabre,  1825,  considers  the  importance 
of  irregular  types  and  forms  of  the  human 
splerti. 

Cheselden,  1831,  records  two  and  three 
spleens  found  in  one  human  body. 

Lebby,  i8.|6,  reports  a  case  of  entire 
absence  of  the  spleen. 

IJainbrigge,  1846,  records  a  case  of  sup- 
plementary spleen,  causing  death  from  the 
patient  being  placed  in  the  supine  position 
in  consequence  of  a  fractured  thigh. 


Ramsay,  1850,  records  a  case  of  gastro- 
enteritis with  entire  absence  of  the  spleen. 

Koranyi,  1857,  contributes  his  study  on 
the  theory  of  wandering  spleen. 

Jameson,  1874,  reports  a  case  of  double 
spleen  and  kidneys. 

Masoin,  1879,  writes  upon  the  artificial 
production  of  atrophy  of  the  spleen. 

Tizzoni,  1882,  records  a  case  of  acces- 
sory spleen. 

Penn,  1885,  reports  a  case  in  which 
there  was  entire  loss  of  the  spleen,  with 
recovery. 

Peevor,  1SS5,  mentions  a  case  of  sup- 
plementary or  second  spleen. 

Younge,  1893,  reports  a  case  of  super- 
numerary spleen. 

Jolly,  1895,  also  reports  one  of  the  same 
character. 

Tedeschi,  1897,  records  a  case  .of  super- 
spleen,  and  Hodenpyl,  1898,  records  a 
case  of  apparent  absence  of  the  spleen, 
with  general  compensatory  lymphatic 
hyperplasia. 

Lanphear  and  Walker,  1903,  found 
three  spleens  in  one  body,  one  of  which 
was  intramesenteric  (personal  communi- 
cation). 

BIBLIOGRAPHY. 

Nenci,  J.     Atti.  accad.  d.  sc.   di  Sienna,   1763, 

ii,  I95-I97- 

Abernethy,  J.  Phila.  Tr.,  London,  1793,  Ixxxiii, 
59  66,  2  pi. 

Fabre,  P.  Soc.  d.  sc.  med.  de  Gannat.  Compt. 
rend.,  Paris,  1825,  xxxix,  104  125. 

Martin,  G.  Bull.  soc.  anat.,  Paris,  1826,  1841, 
i,  40. 

Gates,  A.  W.  New  York  Med.  and  Phys. 
Journal,  1829  30,  iii,  120. 

Cheselden,  W.  Phila.  Tr.,  1700  20,  2  ed., 
London,  1831,  iv-v,  252. 

Lonneman,  R.  De  splenitide  adjunctis  hujus 
morbi  casibus.     Groningae,  1845. 

Lebby,  R.  Southern  Journal  of  Medicine  and 
Pharmacy,  1846,  i,  481  483. 

Bainbrigge,  W.  H.  London  Med.  Gaz.,  1846, 
xxxviii,  1052. 

Ramsay,  H.  A.  Charleston  Med.  Journal  and 
Review,  1850,  v,  728-732. 

Diet),  J.  Pam  Towarz  lek.  Warsawa,  1854, 
xxxi,  50-64. 

Scholz.     Allg.  wien.  med.  ztg.,  1856,  i,  32. 

Koranyi,  F.  Orvosi  hetil,  Budapest,  1857,  i, 
289,  305,  321. 

Luczkiewicz.  Pam  Towarz  lek.  Warsawa, 
1857,  xxxviii,  13-55. 

Ferrant.  Bull.  soc.  anat.,  Paris,  1861,  xxxvi, 
264-267. 

Bruzelius.  Forh.  v.  Svens.  lak-sallsk.  sam- 
mannk.,  Stockholm,  1872,  332  336. 

Jameson,  Ci.  W.  Indian  Med.  Gaz.,  Calcutta, 
1874,  '^t  i^- 

Gruber,  W.  Arch.  f.  path,  anat.,  Berlin,  1875, 
1-^v,  397,  I  pi. 


96 


SURGERT  OF  THE  SPLEEN. 


Kispert,  G.  Am.  sc.  ginec  espan.,  Madrid, 
1878,  iv,  155-160. 

Bernabei,  C.     Imparziale,  Firenze,    1879,  xix, 

132  149- 

Tizzoni,  G.  Sulle  milze  accessorie  e  sulla  neo- 
formazione  della  niilza  per  processi  patologici 
della  milza  primaria,  Roma,  1882. 

Penn.  W.  W.  Texas  Courier  Record  of  Medi- 
cine, 1885  6,  iii,  453  455. 

Peevor,  G.  H.  Indian  Med.  Gazette,  Calcutta, 
1885,  XX,  216. 

D'Aguanno,  Bellet  A.  Morgagni,  Milano, 
1888,  XXX,  605  60S. 

Bonome,  A.  Riv.  clin.,  Milano,  1888,  xxvii, 
886-899. 

Fink,  G.  H.  Indian  Med.  Gazette,  Calcutta, 
1890,  XXV,  334. 

Younge,  G.  H.  British  Med.  Journal,  Lon- 
don, 1893,  i,  ii6r. 

Malins,  E.     Lancet,  London,  1894.  ii,  627. 

Jolly.     Bull.  soc.  anat.,  Paris,  1895,  1^^'  74^- 

Bureau,  P.  Gaz.  hebd.  de  med.,  Paris,  1896, 
xliii,  349-354  (Abstr.). 

Pinzani,  E.  Gazz.  d.  osp.,  Milano,  1896,  xvii, 
1089  1091, 

Jolly.  Rev.  mens.  d.  mal.  de  I'enf.,  Paris, 
1896,  xiv,  439. 

Tedeschi,  A.  Gazz.  d.  osp.,  Milano,  1897,  xviii, 
1017-1020,  954. 

Hodeupyl,  E.  Med.  Record,  New  York,  1898, 
liv,  695  698. 

Gouraud.  Bull.  et.  mem.  soc.  anat.,  Paris, 
1900,  6s,  ii,  480-481. 

DISPLACEMENT  OF  THE   SPLEEN 
(1746-I9O3). 

Displacement  of  the  spleen  is  quite  fre- 
quent, and  may  be  of  any  degree  from  a 
slight  displacement  to  occupying  almost 
any  position  within  the  abdominal  cavity. 
It  may  be  due  to  injury,  disease,  or  re- 
laxation of  the  ligaments  from  any 
cause. 

A  floating  spleen  may  cause  intestinal 
strangulation,  and  it  may  be  congenital  or 
acquired.  It  may  be  mistaken  for  any  of 
the  abdominal  organs. 

Historical. — Kreysig,  1746,  gives  an 
illustration  of  displacement  of  the  spleen. 

Piorry,  1845,  reports  a  case  of  intermit- 
tent fever  caused  by  displacement  of  the 
lower  part  of  the  spleen. 

Ecker,  1847,  descjibes  displacement  of 
blood  corpuscles  in  the  spleen. 

Lescher,  1850-51,  a  case  of  remarkable 
change  in  position  of  the  spleen  and  ab- 
scess of  same. 

Kuchenmeister,  1856,  suggests  remedies 
for  wandering  spleen. 

Buss,  1868,  reports  misplacement  of  the 
spleen  in  connection  with  the  hemorrhagic 
diathesis. 

Baryholm,  1S68,  reports  a  case  of  float- 
ing spleen. 


Kums,  1869,  reports  a  displacement  of 
the  spleen  with  intestinal  strangulation. 

Velasco,  1875,  mentions  a  case  of  dis- 
placement of  the  spleen  in  an  infant. 

Reed,  1877,  a  case  of  movable  and  en- 
gorged spleen,  post-mortem. 

Picard,  1879,  mentions  changes  in  the 
volume  of  the  spleen. 

Schenck,  18S0,  reports  displaced  spleen 
mistaken  for  sub  peritoneal  fibroid  of  the 
uterus. 

Riggs,  1881,  tells  of  dislocated  spleen 
in  hypogastric  region  in  a  woman,  eight 
years'  duration. 

Ogilvie,  1891-93,  mentions  a  case  of 
unusual  mobility  of  the  spleen. 

Collins,  1S95-6,  reports  a  case  of  pelvic 
spleen. 

Crowly,  1S96,  mentions  a  case  of  mis- 
placed and  rotated  spleen  which  simulated 
an  ovarian  tumor. 


BIBLIOGRAPHY. 

Kreysig,  J.  D.  Ad  illustrandum  vexatum, 
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Piorry.     Gaz.  d.  hop.,  Paris,  1845,  vii,  128,  291. 

Etker.     SchatThausen,  1847,  xxxii,  115-119. 

Lescher,  J.  J.  Northwest.  Med.  and  Surg. 
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Batchelor,  J.  C.  Proc.  Med.  Ass.,  Alabama, 
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Christiansen.  N.  pract.  tijdschr.  v.  de  Ge- 
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Kuchenmeister,  G.  F.  H.  Wien.  med.  Woch., 
1856,  vi,  433. 

Buss,  H.  Med.  Times  and  Gazette,  London, 
1868,  ii,  530. 

Baryholow,  R.  West  Jour.  Medicine,  Indian- 
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Tasso.  F"  Gazz.  med.  ital.  prov.  veneto,  Pa- 
dova,  1868,  xi,  353  355. 

Kums.  Ann.  soc.  de  med.  d'anvers,  1869,  xxx, 
363  366. 

Kilpatrick,  A.  R.  Soulh.  Med.  Record,  At- 
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Velasco,  I.  Gac.  med.  de  Mexico,  1875,  x, 
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Schenck,  P.  V.  St.  Louis  Courier  of  Medi- 
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Riggs,  B.  H.  Med.  Record,  New  York,  i88r, 
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SURGERT  OF  THE  SPLEEN. 


97 


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Picou,  Raymond.  De  la  situation  normale  de 
la  rate  par  rapport  a  la  parol  thoracique  chez 
I'adulte.     Paris,  1896,  55  p. 

Sutton,  J.  B.     British  Med.  Journal,  London, 

1897,  i,  132. 

Malkoff,  G.  M.  Bolnitsch.  Gaz.,  Botkina, 
St.  Petersb.,  1897,  viii,  177,  222,  271. 

Sutton,  J.  B.  Tr.  Med.  Soc,  London,  1896  7, 
XX,  95  103. 

EXPERIMENTAL     (1735-I9O3). 

The  experimental  work  pertaining  to 
the  surgery  and  physiology  of  the  spleen 
was  commenced  by  Deisch,  in  1735,  who 
recorded  many  such  experiments  upon 
dogs. 

It  has  been  shown  that  an  animal  or 
human  being  can  live  after  its  spleen  has 
been  totally  removed. 

There  have  been  many  experiments  upon 
the  spleen  to  determine  its  physiology,  but 
as  yet  it  has  not  been  definitely  deter- 
mined. That  it  has  something  to  do  with 
the  leucocyte  there  seems  to  be  no  doubt, 
but  its  exact  function  seems  never  to  have 
been  discovered. 

Its  office  seems  to  be  identical  through- 
out animal  life. 

To  John  Harley,  1857,  is  given  the 
credit  of  having  removed  both  the  spleen 
and  suprarenal  capsules  from  a  rat,  which 
continued  to  live. 

Historical. — Deisch,  i735i  recorded  his 
experiments  upon  dogs  concerning  the 
spleen. 

Chailly,  1822,  published  his  researches 
concerning  the  functions  of  the  spleen. 

Dobson,  1830,  carried  on  a  series  of 
experiments  concerning  the  structure  and 
functions  of  the  spleen. 

Nivet,  1838,  made  extended  researches 
concerning  engorgement  and  hypertrophy 
of  the  spleen. 

Pages,  1846,  experimented  on  living 
animals  to  show  the  instantaneous  decrease 


of  the  spleen  under  the  influence  of  alco- 
hol and  quinine. 

Beclard,  184S,  also  conducted  exten- 
sive experimental  research  concerning  the 
functions  of  the  spleen. 

Rayer,  1849,  published  his  observations 
and  experiences  on  the  contractibility  of 
the  spleen. 

Kuchenmeister,  1S51,  experimented  on 
the  influence  of  quinine,  gentian,  and 
squills  on  a  spleen. 

Jaschkowitz,  1856,  conducted  a  series 
of  experiments  concerning  the  pathology 
of  the  spleen. 

Sappey,  i860,  published  his  researches 
on  hypertrophy  of  the  spleen. 

Estor  and  Saint-Pierre,  1865,  made  ex- 
periments to  discover  how  the  spleen 
worked. 

Philpeaux,  1866,  experimented  to  de- 
monstrate that  the  spleen  taken  from 
young  animals  and  replaced  in  the  abdom- 
inal cavity  becomes  grafted  and  develops 
or  continues  to  have  life. 

Bochefontaine,  1873,  gives  his  notes  on 
experiments  relative  to  the  influence  of 
tying  of  the  splenic  artery. 

Servel,  1876,  experimented  extensively 
on  the  physiology  of  the  spleen. 

Masoin,  1879,  wrote  upon  the  artificial 
production  of  atrophy  of  the  spleen. 

Masoin,  1880,  published  his  experimen- 
tal researches  on  a  withered  congenital 
and  enlargement  of  the  spleen. 

Tizzoni,  1883,  published  his  experimen- 
tal researches  on  the  reproduction  of  the 
spleen. 

Grigorescu,  1886,  recorded  his  experi- 
mental researches  on  the  normal  physiology 
and  pathology  of  the  splenic  circulation. 

Von  Limbeck,  1889,  published  his  ex- 
perimental study  of  leukocytosis. 

Panski,  1890,  contributed  his  experimen- 
tal research  considering  pigmentation  of 
the  spleen. 

Eliasberg,  1893,  made  an  exhaustive 
experimental  study  of  the  spleen  and 
blood-building. 

Ruzicka,  1893,  experimented  concerning 
leukocytosis. 

Botazzi,  1895,  contributed  his  experi- 
mental research  on  the  physiology  of  the 
spleen. 

Lote,  1901,  experimented  on  anthrax 
of  the  spleen. 

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98 


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I 


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Colpi,    A.     Suil    attivita    distruggitrice    della 


SURGERY  OF  THE  SPLEEN. 


99 


milza  verso  il  bacillo  del  carbonchio  nell  infezione 
carbonchio?a  sperimentale  note  preventiva  (Pa- 
dova),  tip.  190U,  7  p. 

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INJURIES      (1696-I903.) 

Injury  of  the  spleen  is  quite  frequent. 
It  is  due  to  traumatism  and  pathologic 
changes. 

Rupture  of  the  spleen  due  to  these  cau?es 
may  be  independent  or  associated  wth 
other  organs  —  kidney,  pancreas,  stomach 
or  liver. 

Spontaneous  rupture  of  a  normal  spleen 
is  highly  improbable. 

Death  may  ensue  as  result  of  hemor- 
rhage, shock  or  infection. 

Historical. — Vanselow,  1696,  gives  the 
history  of  a  case  of  rupture  of  the  spleen, 
while  Valentinus,  171 1,  describes  one  of 
rupture  in  a  homicide. 

Scheid,  1725,  exhibited  a  specimen  of 
ruptured  spleen  with  a  report  of  the  case. 

ZopfF,  1740,  records  a  case  of  rupture 
of  the  spleen. 

Sporing,  1 775'  records  a  case  of  rupture 
of  the  spleen. 

Pyle  and  Wunder,  17S9,  mention  a 
similar  case  of  rupture. 

Chisolm,  iSii,  reports  a  case  of  rupture 
of  the  spleen  and  liver  by  external  injury. 

Audouard,  1827,  considers  sanguineous 
congestions  and  intermittent  fevers  as  a 
cau.se  of  rupture  of  the  spleen. 

The  excessive  use  of  alcohol  is  ascribed 
by  Thompson,  1829,  as  being  the  cause 
of  ru]  ture  of  the  spleen  in  a  case  reported 
by  him. 

Campbell,  1836,  records  a  case  of  rup- 
ture of  the  spleen  and  kidney. 

Hamilton,  1841,  records  rupture  of  the 
spleen  due  to  violence. 

Vigla,  1844,  records  his  observations 
and  researches  concerning  the  spontaneous 
rupture  of  the  spleen. 

Malherbe,  18^7,  reports  a  case  of  rup- 


ture of  the  spleen  due  to  its  tubercular- 
ization. 

See,  1852,  and  Saurel,  1852,  each  record 
a  case  of  traumatic  rupture  of  the  spleen. 

Dalton,  1852,  reports  one  in  a  case  of 
metastatic  abscess  resulting  from  a  com- 
pound fracture  of  the  thigh. 

Swaving,  1854;  Bowie,  1855;  and  Col- 
lins, 1855,  each  report  a  ca?e  of  sponta- 
neous rupture  of  the  spleen. 

Waring,  1856,  reports  three  cases  of 
ruptured  spleen,  with  remarks  on  the  dif- 
ferent organic  changes  which  gave  rise  to 
this  lesion  and  the  different  modes  in 
which  it  may  occur. 

vSalter,  1857,  records  a  case  of  recovery 
following  rupture  of  the  spleen. 

Aufrecht,  1866,  records  a  case  of  rupture 
in  miliary  tuberculosis  of  the  spleen. 

Kralezyfiski,  1867,  records  a  case  of 
rupture  of  the  spleen,  with  hemorrhage 
into  the  abdominal  cavity,  resulting  in 
death. 

A\  hitney,  1869,  mentions  a  case  of  lacer- 
ation of  the  spleen  in  pregnancy. 

Love,  1 87 1,  records  a  case  of  rupture 
of  the  spleen,  with  discharge  through  the 
alimentary  canal. 

vStone,  1876,  reports  a  case  of  rupture 
of  the  spleen  due  to  muscular  exertion. 

Greene,  1880,  reports  one  due  to  the 
same  cause. 

Chrostowski,  1884,  considers  ruptures 
of  the  spleen  in  general,  and  two  cases  of 
the  spleen  in  the  course  of  abdominal 
typhus. 

Dock,  1888,  records  two  cases  of  rupture 
of  the  spleen  from  traumatism. 

Coville,  January,  1902,  describes  a  trau- 
matic rupture  of  the  spleen,  with  slow 
hemorrhage, 

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SURGEET  OF  THE  SPLEEN. 


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630. 


SURGERJ-  OF  THE  SPLEEN. 


Vincent,  E.  Rev.  de  chir.,  Paris,  1893,  ^'''i 
449  579- 

Munson,  E.  L.  Yale  M.  N  ,  New  Haven, 
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Ramdoiir,  W.  Arch.  f.  path,  anat.,  Birlin, 
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1901,  xxvii,  40-45 

Coville.  Gaz.  dcs.  hop.,  Paris,  January,  1902, 
p.    lOI. 

TUBERCULOSIS    (1838-I9O3). 

Tuberculosis  of  the  spleen  demands 
radical  removal  of  llie  tissue  involved, 
whether  it  be  a  partial  or  total  extirpa- 
tion. 

Drainage  may  or  may  net  be  necessary. 

Several  splenectomies  are  reported  for 
general  tubercular  involvement  of  the 
spleen. 

The  spleen  resists  tubercular  disease 
probably  better  than  any  of  the  abdominal 
viscera. 

It  is  usually  secondary,  rarely  primary, 
and  oftener  miliary. 

It  may  involve  a  part  or  all  of  the  or- 
gan, and  become  caesous,  cystic,  or  both. 

It  is  usually  found  at  autopsy  or  by  ex- 
ploratory incision. 

It  may  be  slow  or  rapid  in  its  develop- 
ment, probably  never   recovering   sponta 
neously. 

Manicatide  {Review  Alcns.  de  Mai.  de 


r R)if.,  June,  1S96)  reports  ten  cases  of 
tubercular  disease  of  the  spleen  found  by 
autopsy  in  children.  He  believes  that  the 
spleen  is  always  larger  in  tuberculosis  of 
children. 

Landowzy  and  Henoch  say  that  hyper- 
trophy of  the  spleen  is  always  present  in 
children  with  tuberculosis,  and  that  gray 
granulation  predominates,  with  conges- 
tion of  the  organ  ;  as  the  child  becoines 
older  the  tubercules  are  caseous,  with  in- 
creased connective  tissue. 

One  had  amyloid  degeneration  of  the 
small  vessels. 

Giant  cells  are  numerous,  but  bacilli 
are  scarce. 

Manicatide  found  that  the  tubercules 
develop  in  the  Malpighian  corpuscles  and 
pulp;  also  in  the  interstitial  tissue  about 
the  veins,  and  even  the  capsules  of  the 
organ. 

RoinanolT  records  a  case  of  priinary  tu- 
berculosis of  the  spleen  in  a  man  eighty 
years  of  age,  who  died  two  days  after  en- 
tering the  hospital.  Collet  and  Galavor- 
din,  to  whom  he  refers,  divide  the  dis- 
ease into  two  types — the  pure  splenic  and 
the  spleno-hepatic.  He  refers  to  nine 
cases  of  primary  tuberculosis  of  the  spleen 
reported  by  the  French  authors,  six  wo- 
men and  three  men  {Roussky  \ratcJi,  Oc- 
tober 5,  1902  ). 

Historical . — Palm,  1S38,  recorded  a 
case  of  hypertrophy  of  the  spleen  due  to 
tiiberctjlosis. 

Eberstaller,  1S42,  mentions  an  interest- 
ing case  in  which  he  discovered  tubercular 
disease  of  the  spleen. 

Coley,  i8^6,  reports  a  case  of  tubercti- 
losis  of  the  spleen.  Alquie,  1847  ;  Chalk, 
1S52  ;  Verneuil,  1854,  each  mention  a 
case  of  tubercular  disease  of  the  spleen. 

Sibley,  1857,  reports  extensive  tubercu- 
lar disease  of  the  spleen  in  a  child  suffer- 
ing from  purpura. 

Sene,  1880,  records  a  case  of  tuberculo- 
sis of  the  spleen  in  which  a  special  histo- 
logical study  was  made. 

Scharold,  1S83,  reports  a  case  of  miliary 
tuberculosis  of  the  spleen. 

^'olpe,  1896,  considers  the  etiology  of 
leucemia  and  tuberculosis  of  the  spleen. 

Tedeschi,  1898,  reports  a  case  of  "  sple- 
nomegalie  pretubercolare." 

Qiienu  et  Bandet,  1898,  record  a  case  of 
primary  tuberculosis  of  the  spleen. 

Auche,  1901,  also  reports  a  case  of  pri- 
mary tuberculosis  of  the  spleen. 


SURGERT  OF  THE  SPLEEN. 


103 


niHLIOGRAPIIY. 

Palm.  Med.  cor.-bl.  d.  Wurtemb.  artzl.  ver 
Stutttr.,  i8.vS,  viii,  129-132. 

Eberstalier,  C.  Oesterr.  med.  Wochen.,Wien, 
1842,  1298-1301. 

Fiorry.  Bull.  acad.  med.,  Paris,  1845-46,  xi, 
607  610. 

Colej.  Tr.  Path.  Soc,  London,  1846  8,  i, 
276. 

Alquie.     Gaz.  d.  hop.,  Paris,  1847,  ix,  343. 

Chalk.     Med.  Times  and  Gaz.,  London,  1852, 

V,  8-12. 

Verneuil.  Bull.  soc.  anat.,  Paris,  1854,  xxix, 
24. 

Sibley,  S.W.  Tr.  Path.  Soc,  London,  1857  8, 
ix,  425. 

Powell.  R.  D.  Tr.  Path.  Soc,  London,  1868-9, 
XX.  366  369. 

Sene.     Bull,  soc  anat.,  Paris,  1880,  Iv,  510  12. 

Scharold,  J.  Aertzl.  int.-bl.,  Munchen,  1883, 
XXX,  352. 

Kiemann.  Rev.  d.  k.  k.  krankenanst.,  Wien 
(1S85),  1886,413. 

Vulpe,  A.  Arch,  internaz.  d.  med.  e  chir., 
Napoli,  1896,  xii,  161  175. 

Hamilton,].  B.  Interuat.  Cli-i.,  Philadelphia, 
1896,  6s  iii,  213  216. 

Hayden,  A.  M.  Tr.  Indiana  Med.  Soc,  1897, 
96  106. 

Hayden,  A.  M.  Jour.  Am.  Med.  Assn.,  1898, 
XXX,  778  780. 

Tedeschi,  G.  Riforma  med.,  Napoli,  1898, 
xiv.,  pt.  I,  2c6,  21Q,  222,  231, 

(4j^ienu  et  Baudet.  Rev.  de.  gynec  et  de  chir. 
abd.,  Paris,   1898,  ii,  317  352. 

Dominico,  H.  Compt.  rend.  soc.  biol  ,  Paris, 
1898  V,  1 193. 

Riforma  med.,  Palermo,  igoo,  ii,  277  280. 

Bender,  X.  Gaz.  d.  hop.,  Paris,  1900,  Ixxxiii, 
375  380,  407  411. 

Auche,  B.  Jour,  de  med.,  Bordeaux,  1901, 
xxxi,  381-384. 

GANGRENE    (1860-1903). 

Gangrene  of  the  spleen  is  one  of  the 
rarest  pathological  changes  taking  place 
within  it. 

It  is  usually  due  to  obstruction  to  its 
blood  supply  by  thrombosis,  calcareous  de- 
posits, new  growths  or  injury. 

BIBLIOGRAPHY. 

Brown,  T.  B.  Indian  Ann.  Med.  Sc,  Cal- 
cutta,  i860  I,  vii,   1 12-5. 

Satterthwaite,  T.  E.  Tr.  N.  Y.  Path.  Soc, 
1879,  iii,    102-104. 

SYPirii.is   (1S69-1903). 

Like  tuberculosis,  syphilis  does  not  fre- 
quently involve  the  spleen. 

It  may  cause  hypertropliy,  gummata,  a 
local  or  general  splenitis. 

Tliere  may  be  one  or  more  cysts,  all  of 
which,  as  a  rule,  will  disap[)ear  under  the 
influence  of  syphilitic  remedies. 


Historical. — Naudier,  1S67,  records  a 
case  of  hypertrophy  of  the  spleen  prob- 
ably due  to  syphilis. 

]Moxon,  1870,  reports  a  case  of  syphilitic 
splenitis,  and  another  such  is  mentioned 
by  Gold,  in  1880. 

Tyson,  1880,  writes  about  an  enlarged 
spleeii  in  a  child  due  to  syphilis,  and 
Sharkey,  1881,  speaks  of  a  gummata  in  the 
human  spleen. 

Tommasoli,  18S7,  contributes  his  study 
of  the  spleen. 

Still,  L896,  considers  the  subject  of 
gumma  of  the  spleen  in  children. 

Guerin,  1900,  and  Chamaides,  1900, 
each  report  cases  of  syphilis  of  the  spleen. 

BIBLIOGRAPHY. 

Naudier.   Bull.  soc.  anat.,  Paris,  1867.  xlii,  297. 

Gregoric     Memorabilien  heilbr.,  1870,  xv,64. 

Moxon.  W.  Tr.  Path.  Soc,  London,  187071, 
xxii,  274  6. 

Weil,  A.  Deutsches  arch.  f.  klin.  med.,  Lei]  z  , 
1874,  xii i,  317  339. 

Gold,  L.  Vrijschr.  f.  dermatol.,  Wien,  i88o, 
vii,  463472,  I  pi. 

Tyson,  W.  J.     Lancet,  London,  1880,  ii,  653. 

Sharkey,  S.J.  Tr.  Path.  Soc,  London,  1881  2, 
xxxiii,  339. 

Nolte,"  A.     Griefswald,  1883. 

Baumgarten.  Arch.  f.  path,  anat.,  Berlin,  1884, 
xc,  36  39. 

Tommasoli,  P.  Gazz.  d.  osp.,  Milano,  1887, 
viii,  708  710. 

Bianchi,  A.  Lavori  d.  cong.  di  med.  int.,  1S88, 
Milano,  1889,  i,  286-288. 

Wolfert,  P.      Wu-zeburg,  1S90. 

Stil',  G.  V.  Tr.  Path.  Soc,  London,  1896  7, 
xlviii,  205  209. 

Guerin,  A.  Arch.  prov.  de  med.,  Paris,  1900, 
ii,  59- 69 

Chamaides,  H.  Beitr.  z.  dermatol.  u.  sjph. 
fe  tschr.  f.  J.  Neumann,  Wien,  1900,  5663. 

OSSIFICATION    (1672-I903). 

The  spleen  is  subject  to  deposits  of  cal- 
careous and  bony  tissues  within  it.  They 
may  be  single  or  multiple,  and  vary  in 
size  from  a  millet  seed  to  two  or  more 
inches  in  diameter. 

The  presence  of  the  depo.'<its  may  cause 
a  localized  or  general  splenitis,  and  single 
or  multiple  cysts,  either  one  of  which 
may  become  infected  and  result  in  ab- 
scess. 

Historical . — Rudnicius,  1673,  records 
a  case  of  bony  deposit  in  the  spleen. 

Wogau,  174S,  mentions  a  case  in  which 
there  was  a  formation  of  foreign  sub-tance 
in  the  human  spleen. 

Plevier,  1761,  reports  one  <f  sinj^ular 
ossification  of  the  splin-u 

Martin,    1814.    gives   a    rcsiintc   of    the 


I04 


SURGERT  OF  THE  SPLEEN. 


various  maladies  of  the  spleen,  especially 
ossification  within  its  substance. 

Bampfield,  182 1,  reports  a  case  of  a 
large  encysted  ossification  arising  within 
the  spleen,  and  attached  to  the  left  lobe  of 
the  liver. 

Baillarget,  1S34,  records  a  case  in  which 
there  were  ossiform  concretions  in  the 
spleen. 

Grandoni,  1S39,  mentions  a  case  of 
concretions  formed  in  the  spleen. 

Porter,  1S51,  and  Ollivier,  1S60,  each 
report  a  case  of  concretions  in  the  spleen 

Lefeuve,  1S61,  reports  a  case  of  phlebo 
Hthes  within  the  spleen. 

Branch,  1863,  reports  one  of  ossifi- 
cation of  the  spleen. 

Brunetti,  1863,  records  one  of  petri- 
faction of  the  spleen. 

Murray,  1S78,  reports  a  case  of  carti- 
laginous degeneration  of  the  capsule  of 
the  spleen. 

Zolontniski,  1885,  reports  a  rare  case  of 
splenitis  due  to  the  presence  of  a  splenic 
calculus. 

Sailer,  1897,  records  a  case  of  calculus 
of  the  spleen. 

BIBLIOGRAPHY. 

Rudnicius,  C.  Misc.  acad.  nat.  curios.,  1672, 
Lipz  et  Francof,  1861,  iii,  247. 

Wogaii,J.C.  De  lienis  humani  fabrica  et 
fundaniente  lethalitatis  violentarum  laudati 
visceris  laesionuin.     Jenae,  1748. 

Plevier,  J.  Spec,  sistens  repertum  singular 
ossificationern  praeternaturaiem  imprimis  spec- 
tans.     Ilarderovici,   1761. 

Martin.  Bull.  fac.  de  ined.,  Paris,  1814.15,  iv, 
289-292. 

Bampfield,  R.  W.  Med.  and  Phjs.  Journal, 
Lond.,  1821,  xlv,   15-18. 

Baillarget.   Bull.  soc.  anat.,  Paris,  i83^.,ix,  194. 

Grandoni,  S.  Ann.  univ.  di  med.,  Milano, 
1839,  xci,  355  367. 

Semprini,  A.  Raccoglitere  Fano,  iS^i,  vii, 
193  198. 

Porter,  E.  M.  New  Jersey  Med.  Reporter, 
1 85 1 -2,  V,  150. 

Ollivier.  Bull.  soc.  anat.,  Paris,  i860,  xxxv,  99. 

Lefeuve.     Bull.  soc.  anat.,  Paris,  1861,  xxxvi, 

235- 

Branch,  J.  Boston  Med.  and  Surg.  Journal, 
1863,  Ixviii,  513. 

Brunetti,  L.  Gazz.  med.  ital.  prov.  venete, 
Padova,  1863,  vi,  41,  i  tab. 

Murray,  W.  F.  Indian  Med.  Gaz.,  Calcutta, 
1878,  xiii,  186. 

Zolontniski,  V.  I.  Russk'  med.,  St.  Petersb., 
1885,  i,  297. 

Ue  Luca  et  Gatta.  Riv.  clin.  e  terap., 
Napoli,  1897,  xix,  594-599- 

Sailer,  J.  Proc.  Path.  Soc,  Philadelphia, 
1897  8,  i,  304. 

Lomonaco,  A.  Suppl.  al  policlin,  Roma, 
1900,  vi,  655  660. 


ANTHRAX    (1S99-I9O3). 

Splenic  apoplexy,  malignant  pustule, 
malignant  anthrax,  black  leg,  quarter 
evil,  each  represent  the  same  disease,  and 
is  due  to  the  micro-organism  called  Bacil- 
lus Chauvaei,  which  from  a  single  center 
may  extend  over  the  body  and  invade  the 
intestinal  tract. 

It  has  not  been  recognized  and  properly 
classified  until  recent  years,  and  while 
occasionally  found  in  man,  is  common  in 
animals,  especially  sheep  and  cattle. 

It  has  been  successfully  treated  by  local 
injections  of  carbolic  acid  and  by  incision. 

Zappulla,  1899,  reported  a  case  of  ma- 
lignant pustule  injected  with  argentini- 
tras,  followed  by  recovery. 

BIBLIOGRAPHY. 

Tedeschi,  A.  Jour,  de  physiol.  et  de  path, 
gan.,  Paris,  1899,  i,  22-37. 

Neave,  E.  F.  M.  Lancet,  London,  1900,  ii, 
1012  1013 

Rendu.  Bull,  et  mem.  soc.  med.  d.  hop., 
Paris,  1900,  xvii,  6. 

Malleree.  Rev.  scient.  du  Bourbonnais 
Moulins,  1900,  xiii,  50  53. 

Intrieri.  F.  Salute  pubb.,  Perugia,  1900,  xiii, 
44. 

Prevost,  C.  Brazil  med.,  Rio  de  Jan.,  1900, 
xiv,  120  111. 

Creel,  M.  P.  Kansas  City  Med.  Index-Lancet, 
1900,  xxi,  51  53. 

Acosta,  D.  Y.  Cron.  med.-quir.  de  la  Ha- 
bana,  1900,  xxvi,  129- 131. 

Laws,  O.  S.  California  Med.  Journal,  San 
Francisco,  1900,  xxi,  6-8. 

Sa,  H.  de.  Brazil  med.,  Rio  de  Jan.,  1900, 
xiv,  130  132. 

Williamson,  G.  A.  British  Med.  Journal, 
London,  1900,  ii,  558  561,  7  fig. 

Clarke,  E.  A.   Lancet,  London,  1900,  ii,  1346-7. 

Prevost,  G.  Brazil  med.,  Rio  de  Jan.,  1900, 
xiv,  103-104. 

Davalosy,  Acosta.  Cron.  med.  quir.  de  la 
Habana,  1900,  xxvi,  145  148. 

Fisher,  E.  W.  Therap.  Gaz.,  Detroit,  1900, 
xvi,  508  510. 

Bousfield,  E.   G.     Lancet,    London,    1900,    ii, 

Lasource,  P.  Vie  med.,  Paris,  1900,  iii,  180- 
182. 

Lesne.     Gaz.  hop.,  Paris,  1900,  Ixxiii,  99-100. 

Cervellera,  D.  Gior.  d.  r.  Escerito,  Roma, 
1900,  xlviii,  869. 

Andrich,  G.  Riv.  veneta  di  sc.  med.,  Venexia, 
1900,  xxxiii,  145. 

Leent,  J.  B.  V.  Centrbl.  f.  bakteriol.,  Jena. 
1900,  xxviii,  737  742. 

Magrassi.     Vita  Brescia,  1900,  xix.  No.  28. 

Magrassi.  Sieroterapia,  Roma,  1900,  iv,  fasc. 
2,  22. 

AlpagoNovello,  L.  Gazz.  med.  di  Torino, 
1900,  Ii,  781-787. 

Caturani,  M.  Practica  d.  med.,  Napoli,  1900, 
i,  No.  1. 


SURGERT  OF  THE  SPLEEN. 


105 


Tartaro,  G.  Gazz.  d.  osp.,  Milano,  1900,  xxi, 
1605  1608,  I   trac. 

Lamalleree,  G.  de.  Cent.  med.  et  pharm., 
Commentry,  1900,  v,  177-179. 

Kaplan,  J.     Beucrs,  Paris,  1900,  62  p. 

Sclavo,  A.  Atti.  d.  r.  accad.  d.  fisiocrit,  Siena, 

1900,  xii,  117. 

Giao.  A.  Rev.  portug.  de  med.  e  cir.  prat., 
Lisboa,  1900,  viii,  299-301. 

Phisalix,  Si.  C.  Compt.  rend.  soc.  de  biol., 
Paris,  1900,  Hi,  773-775. 

Guerin,  C.  Echo  med.  du  Nord  Lille,  1900, 
iv, 431-8. 

Bell,  J.     Lancet,  London,  1900,  i,  1005  1006. 

Lancet,  London,  1900,  i,  i6'4-i65. 

Levschine,    L.    L.     Klin.   J.    Mosk,    1900,    iv, 

533- 540- 

Corradi,  G.     Genova  Riv.  d'lg.  e  san.  puhb., 

Torino,  1900,  xi,  530-537. 

Zamboni,  A.  Corriere  San  Milano,  1900, 
xi,  403. 

Liscia,  A.  Gazz.  d.  osp.,  Milano,  1900,  xxi, 
898-899. 

Cursino.  Rev.  med.  de  s.  Paulo,  1900  iii, 
97  98. 

Monge,  A.     Espana,  Madrid,  igoo,  i,  148-151. 

Gerda,  J.  Rev.  balear  de  cien.  med.,  Palnia 
de   Mallorca,  1900,  xix,  273  277. 

Castro,  J.  G.  Siglo  med,,  Madrid.  1901,  xlviii, 
84  86. 

Trista,    R.     Cron.    med.quir.   de    la    Habana, 

1901,  xxvii,  128,  131. 

MuUer,  O.  Arch.  f.  physik.-diat.  ther.  Berlin, 
1901,  iii,  62. 

Carothers,  R.  Am.  Jour.  Dermatol,  acad. 
Genito-Urin.  Dis.,  St.  Louis,  181,  v,  109-T 13. 

Kidd,  A.     Lancet,  London,  1901,  i,  246  247. 

Martelli,  V.  Rassegna  internaz.  d.  med.  mod., 
Catania,  1901,  ii,  124  126. 

Ilanasiewicz,  O.  Militaerarzt,  Wien,  1901, 
XXXV,  94  95. 

Phisalix,  C.  XIII  Cong,  intcrnat.  de  med., 
sect,  de  patho.  exper.,  1900,  Paris,  1901,  compt. 
rend.  28  31. 

Mannoni,  C.  Paris  imp.,  L.  Boyer,  1901. 
No.  177,  63  p. 

Corradini-Rovatti,  G.  Gazz.  med.  Lomb., 
Milano,  lix,  463. 

ABSCESS     (1732-1903). 

Abscess  of  the  spleen  may  be  acute  or 
chronic,  usually  the  former,  and  involves 
a  part  or  all  of  the  gland.  It  is  usually 
due  to  traumatism  and  infection  of  various 
kinds  of  cysts. 

Simple  embolism  is  rare. 

Simple  splenitis  may  become  infected 
and  result  in  abscess,  may  be  primary  or 
secondary. 

The  most  frequent  way  for  them  to  rup- 
ture is  into  the  stomach.  They  may  rup- 
ture through  the  diaphragm  into  the  pleu- 
ral cavity,  into  the  lung,  and  escape 
through  the  bronchus ;  tliey  may,  how- 
ever, rupture  into  the  intestinal  tract, 
peritoneal  cavity,  through  the  abdominal 
wall  or  vagina. 


Recovery  may  be  spontaneous  any 
course  the  pus  pursues. 

The  diagnosis  of  splenic  abscess  is  very 
uncertain,  and  its  removal  by  incision  an 
established  surgical  procedure. 

Historical. — Schlichting,  i733i  reports 
a  case  of  abscess  of  the  spleen  rupturing 
through  the  vulva. 

Coze,  1790,  mentions  an  abscess  of  the 
spleen  rupturing  into  the  stomach. 

Jacquinelle,  1791,  mentions  a  case  of 
abscess  of  the  spleen  rupturing  into  the 
colon. 

Berends,  1829,  mentions  a  tubercular 
abscess  of  the  spleen. 

Raiken,  1S29,  reports  a  case  of  splenitis 
terminating  in  suppuration. 

Hauck,  1S29,  mentions  one  of  a  similar 
character. 

Hickman,  1S31 ,  reports  a  case  of  abscess 
of  the  spleen  communicating  with  the 
stomach  and  umbilicus. 

Holly,  1847,  reports  a  case  of  inflam- 
mation of  the  spleen,  terminating  in  sup- 
puration. 

Newham,  1849,  reports  an  abscess  of 
the  spleen  opening  through  the  left  lung 
above  the  clavicle. 

Law,  185 1,  records  a  case  of  abscess  of 
the  spleen  communicating  through  the 
diaphragm  with  a  gangrenous  cavity  of 
the  left  lung,  associated  with  portal  phle- 
bitis. 

Pullen,  1853,  considers  a  case  of  abscess 
of  the  spleen  with  evacuation  of  pus 
through  abdominal  wall,  with  recovery. 

Lyon,  1853,  records  several  cases  of 
abscess  of  the  spleen,  with  remarks  on 
pathology  of  that  organ. 

Mantell,  1853,  records  a  case  of  abscess 
of  the  spleen  that  discharged  into  the  left 
lung. 

Vinogradoff,  1868,  records  an  abscess 
of  the  spleen  opening  externally,  with 
recovery. 

Alexander,  1873,  reports  a  case  of  in- 
flammation of  the  spleen,  abscess  and 
peritonitis. 

Brown,  1878,  records  a  case  of  abscess 
of  the  spleen,  with  perforation  of  the 
large  intestine. 

Murray,  1880,  abscess  of  spleen,  extend- 
ing to  and  involving  the  liver. 

Chandra,  i88(\  records  an  abscess  of  the 
spleen,  with  free  drainage  and  recovery. 

Jouckh,  1 88 1,  mentions  a  case  of  abscess 
of  the  spleen  emptying  intself  through 
the  lung. 


io6 


SURGERT  OF  THE  SPLEEN. 


Bull,  18S2,  records  a  case  of  abscess  of 
of  the  spleen,  with  perforation  into  the 
stomach,  resulting  in  death. 

Sawyer,  18S4,  records  a  case  of  abscess 
of  the  spleen,  followed  by  excessive  hem- 
orrhage of  the  bowels,  with  eventual  re- 
covery. 

Fleming,  1SS9,  records  a  case  of  absence 
of  the  spleen  resulting  from  injury. 

Cromwell,  1S93.  mentions  a  case  of  sup- 
purative splenitis  caused  by  tight  lacing 
and  violent  exercise,  with  recovery. 

Findlay,  1893,  records  a  case  of  splenic 
abscess,  secondary  abscesses  in  the  liver; 
death  from  pyemia. 

Law,  1S94,  published  his  notes  on  a  case 
of  perisplenic  abscess. 

Winnett,  1S97,  records  a  case  of  abscess 
of  the  spleen,  followed  by  typhoid  fever. 

Desplats,  1900,  records  a  primary  abscess 
of  the  spleen  rupturing  into  the  stomach. 

Von  Eberts,  E.  M.,  1902,  records  a  ma- 
lignant pustule  of  the  spleen. 

BIBLIOGRAPHY. 

Schlichting,  J.  D.  Phila.Tr.,  London, 1732-44, 
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Westphal,  A.  Actaacad.  nat.  curios.,  Norimb., 
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Martin,  G.  Bull.  soc.  anat.,  Paris,  1826,  1841, 
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iJerends.  Operum  postumorum,  Berolini,  1829, 
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Hauck,  F.  F.     Diss  sistens  observationem  sup- 
parationis  lienis  cum  insecuta  suppuratione  cere- ' 
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Cooper.  London  Med.  and  Surg.  Journal, 
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RodionolT.  Vrach  Vaidoin,  St.  Petersb.,  1881, 
vi,  2007. 

Joukh,  N.  Med.  vestnik.,  St.  Petersb.,  1881, 
xxi,  73, 


SURGERl-  OF  THE  SPLEEN. 


107 


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xvii,  53. 

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Petersb.,  1882,  ii,  477-480. 

Le  Bobinnec,  F.  Arch,  de  med.  nav.,  Paris, 
1883,  xxxix,  225-228. 

Bishop,  S.  (J.  Indian  Med.  Gaz  ,  Calcutta, 
1883,  xviii,  75. 

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Heineman.  Med.  Record,  New  York,  1883, 
xxiv,  413. 

Partsevski,  A.  S.  Aspiratsiei  med.  Obozr., 
Mosk.,  1883,  XX,  453-460. 

Coates.  Indian  Med.  Gaz.,  Calcutta,  1883, 
xviii,  347. 

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1883,  li,  90. 

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London,  1887,  ii,  1047. 

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xiii,  1098. 

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London,  1888,  i,  586 

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XXxiv,   22J-229. 

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1889,  V,  201. 

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viii,  111-117. 

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1896,  ii,  1 1 16. 

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Neb.,  1897,  ii,  loo 

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483-487. 

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Desplats.     Echo   med.,   Toulouse,    1900,    xiv, 

534- 538- 

Desplats.  Jour.  d.  sc.  med.  de  Lille,  1900, 
xxiii,  217-223. 

Von  Eberts.  E.  M.  Montreal  Med.  Journal, 
April,  1902,  p.  267. 

HYDATID  CYSTS    (1S25-I9O3). 

EcJiinococci. — This  is  the  most  common 
form  of  cysts  found  in  the  spleen. 

They  may  be  single  or  multiple,  and 
attain  an  enormous  size. 

They  may  be  primary  or  secondary, 
usually  primary,  and  occur  at  any  age. 

They  may  result  ia  recovery  by  spon- 
taneous rupture  into  the  stomach,  intes- 
tines, through  the  diaphragm  and  lung 
into  the  bronchus,  and  become  expecto- 
rated ;  or  externally  through  the  abdominal 
wall.  They  may  rupture  into  the  perito- 
neal cavity,  and  cause  death  ;  or  they  may 
rupture  into  the  alimentary  tract  with 
recovery. 

The  results  of  free  incision  and  drain- 
age have  been  very  satisfactory,  even 
when  the  cysts  have  involved  the  greater 
portion  of  the  organ.  Such  an  operation 
offers  the  only  hope  in  this  class  of  cases. 

In  a  few,  complete  removal  of  the 
spleen  may  be  necessary.  Several  cases 
have  been  reported  in  which  complete 
splenectomy  was  made. 

HIBLIOGRAPHY. 

Bouilland,  J.     Jour.  Univ.  d.  sc.  med.,  Paris, 
1825,  xl,  366-368. 
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68  72. 

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Blair,  J,  Austral  Med.  Journal,  Melbourne, 
1873,  xviii,  102-105. 

Lefevre,  C.     Paris,  1875. 


io8 


SURGERT  OF  THE  SPLEEN. 


Winckel,  F.  Ber.  a.  d.  k.  sachs.  entbind.  inst. 
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xxiii,  779-791. 

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1889,  XV,  612-614. 

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xviii,  15 19. 

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Petersb.,  1898,  iii,  588. 

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iv,  561-582. 

Yakovlyoff,  M.  P.  Laitop.  russk.  chir.,  St. 
Petersb.,  1898,  iii,  5S4-587. 

Q^ienu  et  uuval.  Rev.  internaz.  de  therap.  et 
Pharmacol.,  Paris,  1898,  vi,  281-286. 

Cavazzani,  G.     Clin,  mod.,  Pisa,  1898,  iv,  348. 

Galozzi,  C.  Atti,  d.  r.  accad.  med.  chir.,  Na- 
poli, 1900,  liv,  102. 

Mortureux,  M.  Des  Kystes  hydatizues  de  la 
rate.     Paris,  1900,  97  p. 

HEMORRHAGE    (1778-I9O3). 

He7)2orrhagc  of  the  spleen  is  rather  in- 
frequent, and  may  be  due  to  injury  or 
pathologic  changes. 

It  may  be  primary  or  secondary,  and  of 
one  or  more  cysts,  which  may  rupture  in 
the  same  manner,  with  the  same  results  as 
other  cysts. 

It  may  recover  spontaneously,  with  or 
without  rupture;  or  infection  may  take 
place,  resulting  in  abscess,  with  all  its 
consequences. 

BIRLIOGRAPHY. 

Bose,  E.  G.  De  sanguine  splenica  conjecturae. 
Lipsiae,  1778. 

Audouard,  M.  F  M.  Des  congestions  san- 
guines de  la  rate  ou  des  obstructions  de  ce  viscere 
vulgairment  appelees  en  anglais  spleen.  Paris, 
1818. 

Prov,  Med.  and  Surg,  journal,  London,  1S43, 
vi,  286  8. 

Mignot.     Bull.  soc.  anat.,   Pari?,    1848,   xxiii, 

155-9- 

Imans.     Nederl.    Lancet,    Gravnnh  ,    1849  50, 

V,  554-575,  I  pl; 

Gunsburg.  Ztschr.  f.  klin.  med.,  Bresl.,  1854, 
v,  308. 

Quiquerez.  Oesterr.  ztschr.  f.  pract.  heilk., 
Wien.,  1863,  ix,  946-949. 

Steffen,  A.  Jahrb.  f.  kinderh.,  Leipz.,  1870-71, 
iv,  334- 

Krah,  C.  Der  blutkriefslauf  in  der  miiz  einer 
neuen  injectionsmethode.     Wurzburg,  1877. 

Bizzozero,  G.,  and  Salvioli,  G.  Centalbl.  f. 
d.  med.  wissensch.,  Berlin,  1879,  xvii,  273. 

Mulvey,  W.  J.  Vet.  Journal,  and  Ann.  Comp. 
Path.,  London,  1886,  xxii,  233-236. 

Archer.  Liverpool  Med.  Chir.  Journal,  1887, 
vii,  218-220. 

Glass,  V.  Die  milz  als  blutbildendes  organ. 
Dorpat,  1889. 


SURGBRT  OF  THE  SPLEEN. 


109 


Rolleston.  Tr-  Path.  Soc,  London,  1891-2, 
xliii,  49. 

Subbotic,  V.     Wien,  med'  presse,  1894,  xxxv, 

1337  40- 

Hoge,  M.  D.  Med.  Record,  New  \  ork,  1895, 
xlviii,  418. 

Sirleo,  L.     Policlin.,  Roma,  1896,  iii,  c,  230. 

Hcnisted,  E.  S.  British  Med.  Journal,  London, 
1896,  ii,  507. 

Ilomans,  J.  Ann.  Surg.,  Philadelphia,  1897, 
XXV,  732  4. 

Litten,  M.  Die  krankheiten  de  milz  und  die 
haemorrhagischen  diathesen.    Wien,  1898,  394  p. 

Kischenski,  Dm.  P.  Med.obozr.,  Mosk.,  1901, 
l'^.  577-586.  I  fig. 

MISCELANEOUS  CYSTS  OF  SPLEEN. 
BIBLIOGRAPHY. 

Barret.  Bull.  soc.  anat, Paris,  1828,  2  ed., 
1845,  "•>  228  232. 

Leudet.  Bull.  soc.  anat.,  Paris,  1853,  xxviii, 
120. 

Poumier.  Bull.  soc.  anat.,  Paris,  1840  i,  xv, 
171. 

Goyrand,  G.     Gaz.  med.,  Paris,  1855,  x,  79. 

Wilkes.  Tr.  Path.  Soc,  London,  1858  9,  x, 
263. 

Bizzozero,  G.  Morgagn.i,  Napoli,  1867,  ix, 
429  432. 

Magdelain,  L.  Des  kystes  sereux  et  acephalo- 
cystiques  de  la  rate  historique  de  la  spleenotomie 
suive  de  qu.xues  reflexions  sur  les  consec^uences 
de  cette  operation.     Paris,  1868. 

Peltier,  G.  Rev.  phot.  d.  hop  ,  Paris,  1871, 
iii,  204  211. 

Marcano,  G.  Progress  med.,  Paris,  1874,  ii, 
262. 

Downes,  A.  J.  Progres?,  Louisville,  1888  9, 
iii,  101-6. 

Hasweli,  J.  F.  Liverpool  Med.  Chir.  Journal, 
1889,  ix,  65-70. 

Gilder,  j.K.  Tr.  South  Car.  Med.  Assn., 
Charleston,  1890,  49-52. 

Pilliet,  A.  H.  Compt.  rend.  soc.  biol.,  Paris, 
1892,  iv,  9057. 

Terrier.  Bull,  et  mem.  soc.  chir.,  Paris,  1892, 
xviii,  661667. 

Hamill,  S.  H.  Tr.  Path.  Soc,  Philadelphia, 
1898,  xviii,  426-S. 

Ileurtaux,  B.  Bull,  et  mem.  soc.  de  chir., 
Paris,  1898,  xxiv,  928-935. 

Virchow,  R.  Berl.  klin.  Woch.,  1898,  xxxv, 
67. 

Baginsky,  A.  Berl.  klin.  woch.,  1898,  xxxv, 
40. 

Benek.     Compt.  rend.  1900,   Paris,   1901,   317- 

323- 

Schmidt,  M.  B.  Arch.  f.  path,  anat.,  Ber  n, 
1901,  16,  F.  iv,  50-71,  I  taf. 

CARCINOMA     (1619-1803). 

Carcinoma  of  the  spleen  is  infrequent, 
and  generally  involves  all  of  its  paren- 
chyma. 

It  may  be  primary  or  secondary,  usually 
primary,  and  is  supposed  to  originate  upon 
its  surface. 

It  may  be  slow  or  rapid  in  its  develop- 


ment, and  attain  a  considerable  size  before 
detection. 

It  may  be  associated  with  one  or  more 
cysts,  which  may  rupture  and  produce 
death  by  hemorrhage. 

Jfistorical . — A.  Fonseca,  1619,  men- 
tions a  case  of  scirrholienis  (spleen),  and 
Gerber,  1655,  and  Schlegal,  1694,  each 
record  such  a  case. 

Ezler,  1723;  Parker,  1850;  and  bridges, 
1868,  each  report  a  case  of  carcinoma  of 
the  spleen. 

Russell,  1872,  records  a  scirrhus  stricture 
of  the  cardiac  orifice  of  the  stomach,  with 
a  pecular  history,  and  death  from  hemor- 
rhage through  sloughing  of  the  spleen. 

Baccelli,  1876,  records  a  case  of  primary 
carcinoma  of  the  spleen,  with  a  histo- 
logical study,  showing  the  association  of 
lympho-sarcoma. 

Verite,  1893,  gives  the  diagnosis  and 
history  of  a  case  of  a  primary  epithelioma 
of  the  spleen. 

BIBLIOGRAPHY. 

Fonseca,  A.  Pro  scirrho  lienis.  In  his  Con- 
sult, med.  fol.  Venetiis,  1619,  145-8. 

Gerber,  F.     De  scirrho  lienis.     Jenae,  1655. 

Schlegal,  P.     De  scirrho  lienis.     Jenae,  1694. 

Ezler,  P.  De  scirrhis  viscerum  occasione  sec- 
tionls  viri  tympanite  defuncti  in  que  praeter  alia 
notatu  digna  scirrhus  lienis  singularis  carnosus 
observatus  fuit.     Wittenbergae,  1723. 

Parker,  E.  H.  New  Hampshire  Jour.  Medi- 
cine, Concord,  1850-51,  i,  104-6. 

Bridges,  V.  R.  Chicago  Med.  Journal,  Con- 
1868,  XXV,  729-734. 

Russell.  Med.  Times  and  Gazette,  London, 
1872,  ii,  7. 

Baccelli,  G.  De  primitive  splenis  carcinomate 
(histologice  lympho- sarcomate)  historia  diag- 
nosis extispicium.     Romae,  1876. 

Verite,  Henri.  Du  diagnostic  de  I'epithelioma 
primitif  de  la  rate  (maladie  de  Gaucher).  Lyon, 
1893.  51  P- 

SARCOMA     (1858-1903) 

Sarcoma  of  the  spleen  is  about  as  fre- 
quent as  carcinoma,  and  may  be  of  any 
variety. 

They  are  slow  in  their  development, 
and  usually  primary. 

They  may  be  due  to  trauma,  probably 
more  frequently  so. 

They  are  usually  hard,  having  the  same 
characteristics  as  other  solid  viscera,  but 
they  may  become  cysts. 

JlistoricaL  —  Orpen,  1858,  reports  a 
case  in  which  the  convex  surface  under- 
neath the  peritoneal  sheath  was  invested 
with  fibro- cartilaginous  tissue  of  bony 
consistency  to  the  extent  of  four  or  five 


suhgert  of  the  spleen. 


lines  in  thickness ;  its  parenchyma  was 
highly  congested,  of  a  reddish  -  brown, 
sarcomatous  appearance. 

Woodward,  1867,  reports  a  case  of  me- 
dullary sarcoma  of  the  spleen. 

DeRitis,  1879, records  a  primary  lympho- 
sarcoma of  the  spleen.  One  of  this  char- 
acter is  also  reported  by  Marcondes,  1888; 
Masi,  1893;   and  Acker,  1895. 

IJIULIOGRAPHY. 

Orpen,  A.  H.  Dublin  Q_iiarterly  Journal  Medi- 
Science,  1858,  xxv,  468. 

Woodward,  L.  Cincinnati  Journal  Medicine, 
1867,  ii,  471. 

De  Ritis,  M.  Movlniento,  Napoli,  1879,  i,  511, 
580,  I  pi. 

Kendall,  II.  Med.  Record,  New  York,  1881, 
XX,  123. 

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The  spleen  is  subject  to  the  formation 
of  new  tissue  due  to  many  causes.  In 
this  class  is  included  all  benign  growths, 
which  are  not  included  in  other  chapters 
of  this  work. 

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"3 


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PATHOLOGY     (1683-I93). 

The  pathology  of  the  spleen  varies  but 
little,  in  variety  and  character,  from  path- 
ology of  other  living  tissues,  as  shown  by 
the  chapters  herein  contained. 

Its  bibliography  is  so  voluminous  and 
varied  that  it  alone  will  be  given. 

BIBLIOGKAPllY. 

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"4 


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SURGERT  OF  THE  SPLEEN. 


"5 


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SURGERT  OF  THE  SPLEEN. 


119 


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anatomie  der  milz.     Wien,  n.  d. 

SPLENOTOMY. 

Splenotomy  is  incising  the  spleen  for 
any  purpose,  such  as  opening  cysts,  re- 
moving neoplasms  and  foreign  bodies. 
Many  such  operations  have  been  success- 
fully made. 

The  introduction  of  an  aspirating  needle 
for  the  purpose  of  removing  or  intro- 
ducing fluid  into  the  spleen  may  be  classed 
under  this  heading. 

Historical. — Goslin,  1880,  reports  a  case 
in  which  he  used  a  hypodermic  injection 
of  ergotin  into  the  spleen  for  chronic 
enlargement. 

Peiper,  1883,  injected  Fowler's  solution 
into  a  parenchymatous  spleen  for  leukemia. 

Vidal  Garin,  1884,  punctured  and  in- 
jected a  splenic  cyst,  resulting  in  a  cure. 

For  further  reports  see  bibliography. 

Aspiration  of  the  splenic  cysts  (pus  or 
otherwise)  has  been  successfully  accom- 
plished in  a  number  of  cases,  but  the 
dangers  are  far  greater  than  when  drained 
through  an  abdominal  incision,  with  or 
without  adhesions  of  the  splenic  capsule 
to  the  abdomieal  wall. 


Peritoneal  infection  and  injury  to  blood 
and  lymphatic  vessels  by  the  trocar  are 
possible  and  highly  probable,  and  for  that 
reason  the  trocar  should  never  be  used. 

An  herniated  spleen  should  be  returned 
to  the  abdominal  cavity  when  possible. 
If  not,  a  part  or  all  of  it  may  be  sacri- 
ficed. 

It  is  probable  that  it  is  only  hernia  of 
long  standing  that  will  offer  much  resist- 
ance. 

The  acute  ones  should  offer  no  serious 
complications  in  their  reduction. 

Wounds  of  the  Spleen. — Lacerated,  in- 
cised and  penetrating  wounds  are  frequent 
and  of  many  varieties. 

Many  of  them  will  recover  without  sur- 
gical interference,  while  there  are  still 
others  that  will  cause  death  from  primary 
or  secondary  hemorrhage,  alone  or  subse- 
quent peritonitis.  Just  where  the  border 
line  is  between  leaving  them  alone  and 
opening  the  abdomen  has  not  been  deter- 
mined. Until  it  has  been  more  accurately 
and  definitely  established  the  treatment 
should  be  most  radical  surgery,  where 
there  is  the  least  doubt,  as  opening  the 
abdomen  will  permit  of  most  accurate 
knowledge  of  the  extent  of  the  injury. 

If  suture,  packing  or  the  ligation  of  a 
bleeding  vessel,  removal  of  clots  or  foreign 
substance  be  necessary,  it  can  be  done. 
If  not  the  incision  may  be  closed  with 
safety,  and  the  knowledge  that  nothing 
has  been  left  undone. 

Mosler  records  fifteen  splenotomies  for 
hydatids.  Six  aspirated,  six  died,  three 
not  recorded 

SPLENECTOMY. 

Removal  of  the  spleen  is  a  time  honored 
operation,  the  ancients  having  removed 
the  normal  spleen  from  runners  to  give 
them  greater  speed.  It  is  done  with  ease 
as  compared  with  the  removal  of  certain 
other  abdominal  organs. 

That  life  may  be  maintained  indefinitely 
without  it,  has  been  proven  by  experi- 
ments upon  animals  and  human  beings 
alike. 

That  a  part  or  all  of  it  should  be  re- 
moved in  certain  conditions  is  without 
question.  It  has  been  successfully  done 
for  hernia,  injury,  hypertrophy,  leukocy- 
themia,  tuberculosis,  new  growth>^  (ma- 
lignant and  benign),  and  cysts,  parasitic 
or  otherwise. 

A  part  or  all  of  it  should  be  retained 


SURGER7'  OF  THE  SPLEEN. 


if  possible  in  all  conditions,  except  when 
malignant. 

There  have  been  more  than  three  hun- 
dred splenectomies  made  on  human  beings 
for  various  purposes. 

It  is  diilicult  to  determine  what  the  rate 
of  mortality  has  been,  but,  in  general,  a 
fair  estimate  would  be  50  per  cent. 

This  can  hardly  be  considered  a  high 
rate  of  mortality  when  the  character  of 
the  cases  and  the  emergency  of  the  work 
is  considered. 

From  1865  to  1875  the  mortality  was  80 
per  cent.  ;  from  1S76  to  1885  .1^5  per  cent.  ; 
from  1886  to  1895  20.68  per  cent.  ;  from 
1896  to  1903  13  to  15  per  cent. 

Conklin  {Med.  Record.,  J"ly  28,  1894) 
tabulates  splenectomies  for  malarial  spleen 
with  eight  deaths. 

Tricomi  {Lc  Mercrcdi) ,  in  1894,  records 
eight  splenectomies  for  various  conditions, 
with  eight  recoveries. 

Zuccarelli  (^Iwcr/ran  A/cd.  and  Surg. 
]hiUct'ni,^\-Ay  I,  1894)  records  two  sple- 
nectomies for  mfalarial  spleen  with  two 
recoveries.  He  gives  an  additional  table 
of  nine  splenectomies  for  movable  spleen 
with  two  deaths  ;  eight  for  simple  hyper- 
trophy, with  three  deaths;  twelve  mala- 
rial hypertrophy,  with  tliree  deaths;  four 
for  leukocythemia,  pseudoleukemia,  two 
deaths. 

(Sutton  {London  Lancet,  No.  3764, 
1895)  recorded  three  successful  splenec- 
tomies. He  recommends  the  operation  for 
simple  or  malarial  hypertrophy,  and  says 
that  the  mortality  is  high  in  leukocythemia 
and  low  in  wandering  spleen,  and  that 
the  principal  dangers  are  shock  and  hem- 
orrhage. 

Spanton  {Britisli  ALed.  yournal,  No- 
vember 2,  1895)  reports  three  splenec- 
tomies :  First,  simple  hypertrophy,  death 
five  hours  from  hemorrhage;  second, 
simple  hypertrophy,  death  eleven  hours, 
from  shock;  third,  simple  hypertrophy 
with  recovery.  His  table  shows  twenty- 
five  splenectomies  for  leukocythemia  with 
only  one  recovery.  Thirty -eight  sple- 
nectomies for  hypertrophy  with  twenty 
deaths. 

Douglas  {Journal  American  ALcdical 
Association ,  April  25,  1896)  reports 
twenty-nine  splenectomies  in  America 
with  eleven  deaths.  In  an  additional  table 
which  he  gives  is  shown  six  splenectomies 
for  hydatids  with  four  deaths,  five  for 
primary  sarcoma  with  two  deaths,  thirty- 


six  for  leukocythemia  with  thirty -one 
deaths. 

Assaky,  Ceci,  Landfois,  Franzolin  and 
Ilartman,  each  had  a  case  recover. 

Again,  Douglas  records  forty-one  sple- 
nectomies for  malarial  hypertrophy  with 
twenty- four  recoveries,  his  own  case  re- 
covering; fifty-nine  for  simple  hypertro- 
phy, with  thirty-four  recoveries,  a  mor- 
tality of  42  per  cent. ;  three  for  simple 
cystoma,  all  recovered;  three  non-trau- 
matic abscess  and  slough,  with  three  re- 
coveries;  two  for  floating  spleen,  with 
one  recovery;  forty  -  three  for  wounds, 
forty-two  recoveries.  In  eight  of  the  forty- 
three  the  part  protruding  was  excised. 

Halm  collected  seven  splenectomies  with 
two  deaths. 

Trinkler  says  the  mortality  in  splenec- 
tomies is  21.7  per  cent. 

Terrier  found  three  twisted  pedicles, 
Hartman  one,  and  Klein  found  one  at 
autopsy. 

The  spleen  should  be  removed  whenever 
the  pedicle  is  found  twisted. 

Schwarz  {N.  1\  Med.  Journal,  No- 
vember, 1903)  gives  ten  clinical  histories 
of  patients  with  hypertrophied  and  dis- 
placed spleen  due  to  malaria,  in  which 
cases  he  performed  splenectomy.  In  six 
cases  he  found  torsion  of  the  pedicle.  In 
some  of  the  patients  the  malarial  symp- 
.toms  disappeared  after  the  operation,  but 
in  others  they  continued,  showing  that 
splenectomy  does  not  cure  malaria. 

splenopp:xy. 

Splenopexy  has  been  performed  in  sev- 
eral cases  with  gratifying  results.  That 
the  aggravated  forms  of  "wandering" 
spleen  should  be  returned  to  its  normal 
position  and  kept  there  by  one  or  more  of 
the  various  surgical  methods  devised  for 
that  purpose  is  without  question. 

IMucker,  1895;  Heydenreich,  1S96,  and 
GreifTenhagen,  1S91,  each  succeeded  in 
anchoring  a  wandering  spleen. 

K^ydygier  first  advised  anchoring  of  the 
spleen. 

Bardenheur  cites  a  case  in  which  he  fixed 
the  spleen  outside  the  cavity  of  the  peri- 
toneum in  the  sub-peritoneal  tissues.  The 
spleen  was  forced  through  a  small  opening 
in  the  peritoneum  ;  the  parietal  peritoneum 
was  then  sutured  to  the  parietal  coat  of 
the  pedicle,  and  thus  communication  with 
the  peritoneal  cavity  was  closed. 

To  ancJior,  pass  the  suture  around  the 


SURGERl-  OF  THE  SPLEEN. 


tenth  rib  and  lower  end  of  viscus  and 
small  sutures  in  fascia  and  connective 
tissue.  Incise  longitudinally  from  tenth 
rib  to  iliac  crest,  then  at  right  angle  to 
upper  end  of  this  incision. 

SPLENORRHAPHY. 

Splenorrhaphy  is  suturing  for  any  pur- 
pose. It  is  done  to  anchor  a  wandering 
spleen,  and  to  close  incisions  or  lacera- 
tions from  any  cause.  It  has  been  dotie 
successfully  many  times. 

The  sutures  should  be  of  silk  or  cat-gut, 
preferably  silk,  and  should  not  be  too  near 
each  other.  They  should  not  come  nearer 
than  one-half  inch  to  the  border  of  the 
incision,  and  only  taut  enough  to  approxi- 
mate the  incised  borders. 

GENERAL    SURGERY. 

Historical. — Clark,  1673,  mentions  a 
case  of  resection  of  the  human  spleen. 

Cruger,  1685,  published  a  case  of  ex- 
cision of  the  human  spleen  to  the  Academy 
of  National  Curiosities. 

Taritoni,  1700,  removed  the  entire 
spleen. 

Ferguson,  1732,  gives  an  account  of 
the  extirpation  of  a  part  of  the  human 
spleen. 

Larry  saw  three  cases  of  laceration  of 
the  spleen  by  weapons,  all  of  which  re- 
covered. 

Young,  1801,  records  a  case  of  enlarged 
spleen  cured  by  actual  cautery. 

Cooper,  Sir  A,,  records  a  case  of  dirk 
wound  of  the  spleen. 

O'Brien,  1816,  mentions  a  case  of  re- 
moval of  the  spleen  without  injury  or 
derangement  to  the  animal  economy. 

Leveille  records  a  sabre  wound  of  the 
spleen  which  recovered. 

Schultze,  1828,  writes  about  the  extir- 
pation of  the  spleen. 

Chapman,  1836,  excised  a  spleen. 

Qiiittenbaum,  during  the  same  year, 
commented  on  hypertrophy  of  the  spleen, 
and  gave  the  history  of  extirpation  of  a 
hypertrophied  spleen. 

Eagle,  1842,  proposed  the  excision  of 
the  spleen  and  tying  the  splenic  artery 
and  vein  as  a  remedy  in  some  professedly 
incurable  diseases. 

Bregoli,  1844,  proposed  a  similar  oper- 
ation. 

Dunglison,  1845,  reports  a  case  of  dis- 
location of  the  spleen  in  which  a  splenec- 
tomy was  made. 


Degaille,  1850,  operated  for  an  infected 
hydatid  cyst  of  the  spleen. 

Rombeau,  1854,  punctured  a  hydatid 
cyst  of  the  spleen  ;   result,  death. 

Kuchler,  1855,  extirpated  a  spleen  with 
tumors  upon  it. 

Dorsey,  1855,  incised  a  spleen  and  broke 
up  adhesion  for  splenalgia. 

Harley,  1857,  exhibited  specimens  of  a 
living  rat  from  which  both  the  suprarenal 
capsules  and  the  spleen  had  been  removed. 
This  exhibition  was  before  the  London 
Pathologic  Society. 

Simon,  1858;  Eggel,  1859;  and  Mar- 
tini, 1859,  each  record  a  case  of  extirpa- 
tion of  the  spleen. 

Gibb,  1S62,  removed  a  spleen  weighing 
fifteen  pounds  from  a  live  dog. 

Skoda,  1864  ;  Pserhofer,  1865  ;  Koeberte, 
1867;  and  Thiernesse,  1867,  each  report 
a  case  of  extirpation  of  the  spleen. 

Pean,  1867,  made  a  splenectomy,  with 
complete  extirpation  of  a  cyst,  in  a  woman 
twenty  years  of  age. 

Hyatt,  1868,  reports  a  wound  of  the 
spleen,  removal  of  portion  ;   recovery. 

Schumann,  1868;  Bryant,  1868,  each 
made  an  extirpation  of  the  spleen ;  the 
latter  was  for  enlargement  of  the  gland, 
attended  by  leukocythemia. 

Pean,  1869,  made  both  an  ovariectomy 
and  a  splenectomy  upon  the  same  pa- 
tient. 

Uterhart,  1869,  removed  a  hydatid  cyst 
of  the  spleen. 

Schindeler,  1870,  extirpated  the  spleen, 
and  Philipeaux,  1870,  made  a  complete 
transverse  section  of  the  spleen. 

Magdelain,  1868,  recorded  a  case  of 
cyst  of  the  spleen,  followed  by  sple- 
notomy. 

Powell,  186S,  discussed  spleen  and  su- 
prarenal capsules  removed  from  a  case  of 
phthisis. 

Bazille,  1871,  reported  a  case  of  com- 
plete hernia  of  the  spleen  due  to  trauma- 
tism. He  applied  a  ligature  to  the  pedicle 
and  removed  the  spleen. 

Wilde,  187 1,  incised  a  hydatid  cyst  of 
the  spleen. 

(ialliet,  1873,  punctured  a  unilocular 
hydatid  cyst  of  the  spleen. 

P^lias,  1873,  had  a  case  of  traumatic 
hernia  of  the  spleen,  in  which  he  made  a 
splenectomy. 

Trafton,  1874,  tapped  the  spleen  with  a 
pneumatic  aspirator. 

Markham,  1874,  made  an  excision  of  a 


SURGERY  OF  THE  SPLEEN. 


portion  of  the  spleen  with  recovery  of  the 
patient. 

Renger,  1874;  Mosler,  1874;  Fowler 
(J.  II.),  1875;  Brochin,  1876;  Barrault, 
1876;  Fowler  (S.  P.),  1876;  Kuster,  1S76; 
Hard,  1877;  Billroth,  1877;  Simmons, 
1877;  and  Goldhaber,  1877,  each  record 
a  case  of  extirpation  of  the  human  spleen, 
the  latter  with  recovery  ((ioldhaber) . 

Browne,  1877,  reports  a  case  of  rapid 
hypertrophy  of  the  spleen  in  which  he 
excised  it. 

Otis,  1877,  gives  a  history  of  a  case  of 
complete  extrusion  of  the  spleen  from  an 
incised  wound,  with  ligature  and  removal 
of  the  spleen  ;   recovery. 

Hammond,  1878,  successfully  aspirated 
the  spleen,  with  recovery. 

Faris,  1868,  made  a  partial  excision  of 
the  spleen,  with  recovery. 

Mori,  1878,  made  a  successful  operation 
for  echinococcus  of  the  spleen. 

Monod,  187S,  made  a  successful  punc- 
ture of  the  apex  of  the  spleen  for  a  hydatid 
cyst. 

Arnison,  1878,  and  Martin,  1878,  each 
made  a  successful  splenectomy. 

Rogers,  1878,  reported  a  case  of  extir- 
pation of  the  spleen. 

Nedopil,  1879,  one  of  laparosplenec- 
tomy,  as  did  Czerny  also  in  1879. 

Roux,  1879,  punctured  an  abscess  of 
the  spleen,  and  injected  with  a  solution 
of  iodoform. 

Goslin,  1S80,  reports  a  case  in  which 
he  used  a  hypodermic  injection  of  ergotin 
into  the  spleen  for  chronic  enlargement. 

Franzolini,  1882,  made  a  splenectomy 
for  hypertrophy. 

Wallace,  1883,  successfully  punctured 
an  abscess  of  ihe  spleen,  with  complete 
drainage;  recovery. 

Crede,  1883,  and  Haward,  1883;  each 
report  a  case  of  splenectomy  ;  while  Collier, 
1883,  questions  the  operation  of  splenec- 
tomy for  leukocythemia. 

Corona,  1883;  Morse,  1882;  and  Blum, 
1883,  each  report  a  case  of  excision  of  the 
spleen. 

Partsevski,  1883,  aspirated  an  abscess 
of  the  spleen. 

Peiper,  1883,  injected  Fowler's  solution 
into  a  parenchymatous  spleen  for  leukemia. 

Younkin,  1884,  made  a  splenotomy  for 
a  wandering  fpleen;   recovery. 

Mollier,  1884,  made  a  splenectomy,  and 
Asdale,  1884,  successfully  removed  the 
spleen  in  a  dog. 


Terrier,  1884,  made  a  splenectomy  for 
hypertrophic  spleen ;  death  from  hemor- 
rhage. 

\'on  Hacker,  1884,  and  ISIosler,  1884, 
each  made  an  extirpation  of  the  spleen. 

\'idal  Garcin,  1884,  cured  a  cyst  of  the 
spleen  by  puncture  and  injection. 

Pietryikowski,  1884;  Biziel,  1884;  Tiz- 
zodi,  1884;  (jilson,  1885;  and  Roddick, 
1885,  each  report  a  case  of  splenectomy. 

Eternod,  1885,  considers  at  length  the 
regeneration  of  the  spleen  after  it  has  been 
extirpated. 

Collier,  1886,  considers  the  cases  of 
splenectomy  made  by  Knowsley  Thornton. 

Lauenstein,  1887,  records  a  case  in  which 
he  opened  an  abscess  of  the  spTeen. 

Chowdlioory,  1887,  reports  a  case  of 
abscess  of  the  spleen  bursting  into  the  left 
lung;   cured  by  operation. 

Donat,  1887;  Deakin,  1887;  (Jovseef, 
1887;  Ceci,  1887;  Casini,  1887;  Pomara. 
1887  ;  and  Vrabie,  1887,  each  record  a  ca>e 
of  splenectomy. 

Hyer,  1887,  reported  an  incised  wound 
of  the  spleen. 

McCann,  1887,  made  a  splenectomy  for 
a  dislocated  or  wandering  spleen,  as  did 
Myers  also  in  1887. 

Podrez,  1887;  Ribera,  1887;  Pennato, 
1887;  and  Orlowski,  1887,  each  made  a 
splenectomy. 

McCiraw,  1888,  excised  a  dislocated 
spleen,  and  the  patient  subsequently  ex- 
pectorated the  ligature  of  the  pedicle. 

Goodell.  1888;  Liebmann,  1888;  and 
Nilson,  1888,  each  made  a  splenectomy, 
the  latter  for  a  floating  hypertrophied 
spleen. 

J'ostempski,  1888,  reports  a  case  of 
laceration  of  the  lung  due  to  contusion, 
with  laparotomy  and  exploration,  and 
splenectomy. 

Severeanu,  1888;  Putti,  1888;  Inotescu, 
1888;  Park,  1888;  Kocher,  1888,  and 
A^ch,  1888,  each  report  a  case  of  sple- 
nectomy. 

Kohler,  1888,  reports  a  case  with  splenic 
tumor  with  ascites  and  anasarca  ;  explora- 
tive laparotomy. 

Ilelmuth,  1888,  reports  a  case  of  .spindle 
(spindle  myeloma)  cell  sarcoma  of  the 
spleen  in  an  infant  eighteen  months  old, 
in  which  he  made  a  splenectomy  ;  the 
tumor  weighed  nine  and  one  half  jiounds. 

Lawrason,  1888  ;  Fussell,  1889  ;  Willien, 
1889;  Hatch,  1889;  D'Antona  1889; 
Beijers,    18S9;     Bond,     1889;     Terrillon, 


SURGERT  OF  THE  SPLEEN. 


123 


1889,  and  Relazione,  1889,  each  report  a 
case  of  extirpation  of  the  spleen, 

Ross,  1889,  reviews  the  list  of  cases  of 
splenectomy  recorded  by  Dr.  Asch,  of 
Breslau,  and   his  deductions  therefrom. 

St.  Lawrence  Hurke,  i8S9,made  a  sple- 
nectomy for  tuberculosis  of  the  spleen. 

Wyman.  1889,  ligated  the  splenic  artery 
for  cure  of  hypertrophy  of  the  spleen. 

KurloflF,  1889,  reported  his  observations 
on  the  alteration  in  the  blood  of  animals 
in  the  course  of  first  year  after  removal 
of  spleen. 

Balls-Headley,  1889;  Spandow,  1SS9; 
Fink,  1889;  Bollici,  1889;  Metzges,  1890; 
Filippoff  and  Kauznezoff,  1890,  each  re- 
port a  splenectomy. 

Fountain,  1890,  reports  a  case  of  abscess 
of  the  spleen  in  which  he  operated  with 
drainage  and  recovery. 

Ledderhose,  1S90;  Ghillini,  1890;  Bar- 
denheur,  1890;  JVIartino,  1890;  Glasgow, 
1890;  De  Renzi,  1890;  Tassi,  1890; 
IMensi,  1891  ;  Bruhl,  1891  ;  Folet,  1891  ; 
Ilolbek,  1891  ;  Due,  1891  ;  Von  Burck- 
hardt,  1S92  ;  Tricomi  and  Lindfors,  1893, 
each  record  a  splenectomy. 

James,  1893,  reports  a  case  of  gunshot 
wound  of  the  spleen  and  diaphragm  in 
which  he  sutured  both,  with  recovery. 

Orlando,  1893  ;  Paine,  1892  ;  Lennan- 
der,  1892:  Emelianoff,  1893;  and  Meero- 
vitsch,  1893,  each  report  cases  of  the  re- 
moval of  spleen,  the  latter  reporting  three 
splenectomies. 

Ilertaux,  1893,  reports  a  splenectomy 
for  displacement  of  the  spleen. 

Cowen,  1893,  reports  a  case  of  splenec- 
tomy for  carcinoma  ;   death  from  shock. 

(jangitano,  1893;  Massopust,  1893; 
Treub,  1893:  Jemoli,  1S93,  each  report 
extirpation  of  the  spleen. 

Riegner,  1893,  removed  the  spleen  for 
traumatism  of  that  organ. 

Paine,  1893;  Pirri,  1893;  Ceci,  1893; 
Postempski,  1894;  Markoe,  1894;  and 
Conklin,  1894,  each  report  one  or  more 
splenectomies,  several  of  which  were 
successful. 

Warbasse,  1894,  wrote  on  the  surgery 
and  physiology  of  the  spleen. 

Wagner,  1894,  extirpated  a  wandering 
sarcomatous  spleen. 

Stemen,  1894,  reports  a  case  of  partial 
removal  of  the  spleen. 

Terrier,  1894,  reports  his  observations 
on  splenectomy  with  torsion  of  the  ped- 
icle. 


Sabbatani,  1894,  records  a  case  of  sple- 
nectomy for  enlargement  of  the  spleen 
due  to  influenza. 

Murphy,  1894,  published  his  notes  on  a 
successful  removal  of  the  spleen. 

Schalita,  1894,  and  Poisson,  1S94,  each 
report  a  case  of  removal  of  the  spleen. 

Jvatzenstein,  1893,  reports  a  case  of 
subacute  pseudo  -  leukemia  in  which  he 
injected  a  solution  of  arsenic. 

Zikoff,  1895,  reports  a  case  of  lacer- 
ation of  the  spleen  which  he  successfully 
sutured. 

Spanton,  1895,  reports  three  such  cases. 

Regnoli,  1895,  made  a  total  extirpation 
of  the  spleen. 

Ilerczel,  1895,  made  a  splenectomy  for 
primary  sarcoma  of  the  spleen. 

Rydygier,  1895,  reports  a  case  in  which 
he  operated  for  wandering  spleen. 

Mueller  and  Staley,  1895  ;  Ketchersid, 
1895  ;  Schalita,  1895  ;  SykoflF,  1895  ; 
Kouwer,  1895;  Salomoni,  1895;  and 
Aievoli,  1895,  each  record  a  splenec- 
tomy. 

IvanoiY,  1895,  speaks  of  the  value  of 
steam  in  surgery  of  the  spleen. 

Delatour,  1895,  records  a  case  of  throm- 
bosis of  the  mesenteric  veins  as  the  cause 
of  death  after  splenectomy. 

Bertini,  1895;  Hahn,  1895;  Markoe, 
1895  ;  Gabbi,  1895  ;  Domenici,  1895  ;  Sut- 
ton, 1895;  Neel,  1895;  Duncan,  1895; 
Hahn,  1896;  Ghetti,  1896;  Douglas,  1896; 
Pitts  and  Ballance,  1896;  Briggs,  1896; 
Lodigiani,  1896;  Rocheblave.  1896; 
Hatchett,  1896;  Jonnesco,  1896;  Bell, 
1896;  Valeggia,  1896;  and  Rakhmanoff", 
1896,  each  report  a  splenectomy,  the  latter 
for  a  wandering  spleen  in  a  pregnant 
woman. 

Guerin  and  Legros,  1896,  report  a  sup- 
puratory  hydatid  cyst  of  the  spleen  with 
perforation  of  the  diaphragm,  in  which  a 
thoracotomy  was  made. 

Bond,  1896;  lonescu,  1896;  Ninni, 
1896;  and  Brown,  1896,  each  report  a 
case  of  splenectomy ;  the  latter  was  for 
the  prolapse  of  spleen  through  a  perforated 
wound  of  the  abdomen  ;   recovery. 

Courmont  and  Duffau,  1897;  Strange 
and  Ware,  1897;  Catellani,  1S97;  Fuller- 
ton,  1897;  Deeble,  1897;  Ilartman,  1897; 
Von  Beck,  1897;  Vaquez,  1897;  Walter, 
1897  Pariyski,  1897;  Strong,  1898;  and 
Mikhailovski,  each  report  cases  of  sple- 
nectomy, the  latter  reporting  nine  such 
cases. 


124 


SURGERT  OF  THE  SPLEEN. 


Jonnesco  (  Gaz.  des  hopitaux,  October 
27,  189S)  reports  twenty-three  cases  of 
splenectomy,  one  for  hydatids,  twenty- 
two  for  malarial  enlargement.  One  died 
from  ihe  operation  and  seven  from  causes 
not  connected  with  the  operation. 

Hartley,  1S98,  made  a  splenectomy. 

Jordan,  1898,  speaks  of  conservative 
surgery  of  the  spleen,  and  mentions  a 
bloodless  method  of  partial  excision  per- 
formed on  twenty-two  dogs  with  twenty- 
one  recoveries  ;  note  of  the  blood  exami- 
nation before  and  after  operation. 

Moulonguet,  1898;  Colorni,  1898;  Van- 
erts,  1898;  Bragagnolo,  1898;  and  Kirch- 
off,  1898,  each  report  a  case  of  splenec- 
tomy. 

Merritt,  1898,  records  a  case  of  explora- 
tory incision  in  an  immense  spleen,  filling 
to  a  great  extent  the  abdominal  cavity. 

Aach,  1898;  and  Sutton,  1898,  each 
report  a  case  of  splenectomy,  the  latter 
for  a  wandering  tubercular  spleen. 

Morestin,  1898;  ZiatarofF,  1898;  Mag- 
liano,  1898;  Quine,  1898;  Laccetti,  1898; 
Parona,  1898;  Tricoma,  1898;  Temoin, 
1898;  Alessandro,  1899;  and  Pugliese, 
1899,  each  report  a  case  of  splenectomy. 

Morrison,  1899,  reports  a  case  of  excision 
of  the  spleen  with  recovery. 

Ricketts,  B.  Merrill,  1899,  made  an  ex- 
ploratory incision  in  a  case  of  enormous 
spleen;  death  in  six  hours.  Man,  aged 
fifty-four. 

Gushing,  1899,  made  a  splenectomy  for 
splenic-anemia. 

Bovee,  1900,  made  a  splenectomy  with 
attempted  surgical  cure  of  ascites  due  to 
scirrhus  of  the  liver. 

Nunez,  1900,  reports  three  splenecto- 
mies for  hypertrophy. 

Dallas,  1900;  Hagen,  1900;  Parlavec- 
chio,  1900;  Chandelux,  1900;  Llobet, 
1900;  Moses,  1900;  Power,  1900;  Men- 
del, 1900;  Nannotti,  i9(X);  Schwarz, 
1900;  Sandoveanu,  1900;  Michailowsky, 
1900;  Cominotti,  1900;  Sokoloff,  1900; 
Ashby,  1901  ;  Jordan,  1901  ;  Mixter, 
1901  ;  McKenna,  1901  ;  Cirillo,  1901  ; 
Warren,  1901  ;  and  Lazanet,  1901,  each 
report  cases  of  splenectomy. 

Harrison,  March,  1902,  reports  a  sple- 
nectomy in  splenic  anemia. 

Earnest,  J.  G.,  1902,  reports  a  splenec- 
tomy. 

McGraw,  T.  A.,  1902,  reports  a  sple- 
nectomy for  leukemic  enlargement. 

Balloch,  1902,  reports  a  traumatic  rup- 


ture of  the  spleen ;  splenectomy ;  death 
on  sixth  day. 

Micili,  1903,  reports  a  case  of  hydatid 
cyst  of  the  spleen  which  recovered  after 
puncture  and  drainage. 

Sappy  records  a  case  of  a  boy,  eleven 
years  old,  who  recovered  from  laceration 
of  the  spleen. 

Webster,  J.  C,  removed  a  spleen  weigh- 
ing twenty -eight  ounces.  The  pedicle 
was  twisted.  Diagnosis  not  made  until 
after  abdomen  had  been  opened.  Recov- 
ery, {your.  Amer.  Med.  Assn.,  April  4, 
1903,  p.  887-891.) 

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SUR0ER7'  OF  THE  SPLEEN. 


137 


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Bois  and  Kerr.  Clinical  Studies  with  Spleen 
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Clark,  A.  C.  The  Therapeutic  Value  of  Spleen 
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Grandis,  V.  Sur  I'echange  retpiratiore  dans 
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Corradi,  G.  La  pustola  maligna  di  origine 
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Nascimbebe,  M.  La  milza  nell  economia  dell 
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Strubell,  A.  Ein  neuer  beitrag  zur  therapie 
des  milzbrandes.  Munchen.  med.  woch.,  1900, 
xlvii,  642  6. 

Leguizamon,  H.  Esplenomegalia  con  cirrosis 
del  higade  enfermedad  de  Banti.  Rev.  soc.  med. 
argent.,  Buenos  Aires,  1900,  viii,  287  295. 

Reich,  C.  Ueber  die  enstehung  des  milzpig- 
ments.     Arch.  f.  path,  anat.,  Berlin,  1900,  15  F., 

X,  378-393- 

Thole.  Ileus  durch  faserkrebs,  der  flexure  coli 
lienalis  bei  einem  20  jahrigen  soldaten.  Deutsche 
mil.  arztl.  ztschr.,  Berlin,  1901,  xxx,  257  275. 

Tomsa,  W.  Die  pymphwege  der  milz.  Wien 
nd.  d. 

Miraglia,  L.  Splenomegalia  per  autointossi- 
cazione.  Arch,  internaz.  di  med.  e  chir.,  Napnli, 
1901,  xvii,  201-206. 

Karewski.  Vorstelhing  eines  falies  von  trau- 
matischer  milznekrose.     D.  utsche    med.  woch., 

1901,  xxvii,  ver  bei,  xxvii,  3. 

Fortin.  R.  De  la  phonendoscopie  etude  pho- 
nendoscopique  de  la  rate.  Paris,  1901,  No.  254, 
60  p.,  2  fig. 

Stachelin  (Arch.  f.  klin.  med.,  vol.  76  no.  4) 
reports  his  observations  on  the  blood  following 
splenectomy. 

Spear.  Jour.  Am.  Med.  Assn.,  August  i,  1902, 
p.  304-305.  Abscess  of  Spleen  ;  Operation  ;  Death 
Six  Days  After. 

Finkelstein  (New  York  Med.  Journal,  July  25, 

1902,  p.  iq6)  records  a  splenectomy  and  Talma's 
operation  for  malarial  ascites  and  enlarged  spleen  ; 
artificial  anastomosis  of  the  portal  circulation  by 
Talma's  method ;  recovery. 

Rogers  (Amer.  Med.   Journal,   September   12, 

1903,  p.  69)  reports  two  cases  of  splenectomies 
for  Bante's  disease  (enormous  hypertrophy  of  the 
spleen  and  liver,  with  ascites  and  low  hemoglobin 
rate),  in  which  most  gratifying  results  were  ob- 
tained. 


V. — Surgery  of  the   Thyroid. 


ANATOMY    (1849-I9O3). 

The  thyroid  gland  in  the  human  body 
consists  of  two  lateral  lobes  united  by  an 
intervening  portion  named  the  isthmus. 
The  right  lobe  is  usually  slightly  larger 
than  the  left.  The  weight  of  the  whole 
gland  is  about  one  ounce.  The  geiieral 
shape  of  the  gland  bears  some  resemblance 
to  that  of  a  horseshoe,  the  concavity  being 
directed  upwards. 

Each  lateral  lobe  is  roughly  pyriform 
in  shape.  The  upper  end  is  smaller;  it  is 
directed  upwards  and  slightly  backwards, 
and  usually  extends  as  high  as  the  middle 
of  the  pof-terior  border  of  the  thyroid  car- 
tilage ;  sometimes  it  extends  as  high  as  the 
upper  border.  The  lower  end  is  broader 
and  more  rounded.  It  commonly  extends 
as  low  as  the  sixth  ring  of  the  trachea. 
Its  relation  to  the  upper  border  of  the 
sternum  varies  according  to  the  position 
of  the  head  and  the  length  of  the  neck. 
When  the  head  is  extended  the  lower  part 
of  the  gland  is  from  half  an  inch  to  an 
inch  above  the  upper  border  of  the  ster- 
num. During  flexion  of  the  head  it  de- 
scends down  to  or  below  this  level. 

The  icppcr  hor)i  of  the  gland  is  that  part 
of  the  lateral  lobe  which  lies  above  the 
level  of  the  upper  border  of  the  isthmus. 
Similarly  the  lorcer  hor/i  is  that  part  which 
lies  below  the  lower  border  of  the  isthmus  ; 
it  is  usually  much  smaller  than  the  upper 
horn  ;  frequently  it  is  altogether  absent. 

The  isthmus  varies  greatly  in  size  in 
different  subjects.  In  rare  cases  it  is  en- 
tirely absent,  the  two  lateral  lobes  being 
quite  separate  from  each  other.  This  is 
the  normal  condition  in  many  of  the  lower 
animals.  It  may,  on  the  other  hand,  be 
thick  and  broad,  covering  several  rings 
of  the  trachea  and  part  of  the  larynx. 
Between  these  two  extremes  every  variety 


in  the  size  and  shape  of  the  isthmus  may 
be  found.  The  isthmus  usually  covers  two 
or  more  of  the  first  four  rings  of  the 
trachea. 

The  py7-afnid  o^  Lalouette,  often  known 
as  the  middle  lobe,  is  an  elongated  portion 
of  gland,  which,  when  present,  extends 
from  the  isthmus  upwards  in  front  of  the 
larynx  for  a  variable  distance.  Some- 
times it  reaches  the  hyoid  bone ;  more 
often  it  covers  only  the  lower  part  of 
the  larynx.  From  its  tip  a  band  of 
connective  tissue  frequently  extends  up- 
wards to  the  back  of  the  hyoid  bone. 
Usually  the  pyramid  is  present  on  one  side 
only,  most  commonly  the  left.  Barely  two 
pyramids  are  present,  in  which  case  one 
at  least  will  be  very  small.  The  pyramid 
becomes  enlarged  like  the  rest  of  the  thy- 
roid gland  when  this  organ  becomes  the 
seat  of  general  enlargement.  It  may  thus, 
by  covering  up  the  cricothyroid  membrane 
and  other  parts  of  the  larynx,  become  a 
source  of  considerable  trouble  in  such 
operations  as  tracheotomy  for  parenchy- 
matous goitre. 

The  Jiilus  is  a  term  used  to  denote  that 
place,  at  the  inner  and  back  part  of  each 
lateral  lobe,  at  which  the  inferior  thyroid 
artery  enters  the  gland.  Here  the  recur- 
rent laryngeal  nerve  comes  into  close  con- 
tact with  the  gland,  lying  in  the  space 
between  it  and  the  trachea  and  esophagus. 

Relatio7is. — The  convex  anterior  surface 
of  each  lateral  lobe  is  covered  by  the 
sterno-hyoid  and  sterno-thyroid  muscles, 
and  overlapped  by  a  portion  of  the  sterno- 
mastoid. 

On  the  outer  side  is  the  carotid  artery, 
enclosed  in  its  sheath  with  the  internal 
jugular  vein  and  pneumogastric  nerve. 
Posteriorly,  in  the  concavity  formed  by  the 
isthmus  and  the  two  lateral  lobes,  lie  the 
trachea,  esophagus, and  recurrent  laryngeal 


SURGERr  OF  THE    TIIVROID. 


139 


nerves.  Small  portions  of  the  larynx  and 
pharynx  are  embraced  by  the  upper  horns, 
which  lie  on  either  side  of  these  struc- 
tures. 

The  posterior  border  of  each  lateral  lobe 
is  in  contact  with  the  spine  and  pre-ver- 
tebral  muscles. 

The  gland  is  invested  by  a  delicate  but 
distinct  capsule  of  connective  tissue.  This 
covers  uniformly  the  anterior  and  lateral 
aspects  of  the  organ.  Passing  round  the 
side  of  the  gland  to  its  posterior  surface, 
this  capsule  then  splits  into  portions.  One 
remains  in  contact  with  the  gland  and 
invests  its  posterior  surface.  The  other, 
the  thicker  of  the  two,  passes  to  the  pos- 
terior surface  of  the  pharynx  and  esopha- 
gus, thus  enclosing  thein  with  the  larynx, 
trachea  and  thyroid  gland  in  a  common 
sheath.  This  is  an  anatomical  point  which, 
as  will  be  seen  hereafter,  is  of  considerable 
importance  in  connection  with  operations 
for  removal  of  the  diseased  gland. 

To  the  cricoid  cartilage  the  gland  is 
most  firmly  connected  on  each  side  by  a 
band  of  connective  tissue  termed  the  sus- 
pensory lioainent.  This  passes  from  the 
inner  and  back  part  of  the  lateral  lobe 
upwards  to  the  cricoid  cartilage.  Blend- 
ing below  with  the  capsule  of  the  gland, 
these  two  bands  form  the  upper  ends  of  a 
kind  of  sling  in  which  the  organ  is  sus- 
pended and  by  which  it  is  firmly  fixed  to 
the  larynx. 

When  the  gland  has  undergone  great 
enlargement  and  is  much  increased  in 
weight,  these  ligaments  become  of  con- 
siderable importance.  They  form  strong 
cords,  supporting  the  tumor,  which  other- 
wise, by  reason  of  its  weight,  would  tend 
to  fall  away  from  the  larynx.  It  should 
be  added  that  the  recurrent  laryngeal  nerve 
lies  in  immediate  contact  with  this  liga- 
ment on  its  outer  or  posterior  surface. 

When  enlarged  to  a  moderate  extent 
the  gland  also  comes  into  relation  above 
with  the  omohyoid  muscle  and  below  with 
the  upper  part  of  the  sternum  and  the 
inner  ends  of  the  clavicles. 

Blood-  J'cssels. — The  thyroid  gland  has 
a  relatively  large  blood  supply.  The  chief 
arteries  are  the  superior  and  inferior  thy- 
roid, the  former  derived  from  the  external 
carotid,  the  latter  from  the  thyroid  axis, 
a  branch  of  the  first  part  of  the  subc- 
lavian. 

The  superior  thyroid  artery  meets  the 
gland  at  the  tip  of  its  upper  horn.     Here 


the  artery  frequently  gives  off  a  large 
branch  which  parses  down  to  the  back  of 
the  gland.  The  artery  then  continues  its 
course  downwards  and  inwards  along  the 
inner  and  anterior  border  of  the  horn  un- 
til it  reaches  the  isthmus,  where,  much 
diminished  in  size,  it  forms  an  anastomo- 
sis with  the  corresponding  artery  of  the 
opposite  side,  along  the  upper  border  of 
the  isthmus.  In  its  course  it  gives  off, 
besides  branches  to  neighboring  organs,  a 
series  of  branches  which  run  downwards 
over  the  anterior  surface  of  the  gland. 
The  smaller  branches  penetrate  the  gland 
and  anastomose  freely  with  the  other  thy- 
roid arteries. 

The  inferior  thyroid  artery,  usually 
considerably  larger  than  the  superior,  runs 
at  first  upwards  ;  it  then  turns  abruptly 
inwards,  runs  behind  the  carotid  sheath 
and  the  sympathetic  nerve  and  reaches  the 
back  of  the  gland.  Here  it  breaks  up  into 
several  branches,  some  of  which  enter  the 
hilus,  while  the  others  spread  out  upon  the 
posterior  surface  of  the  gland.  The  close 
proximity  of  the  artery  to  the  recurrent 
laryngeal  nerve  is  of  much  importance. 
Usually  the  main  trunk  of  the  artery  passes 
behind  the  nerve ;  sometimes  the  artery 
breaks  up  before  reaching  the  nerve;  in 
this  case  one  or  more  of  the  branches  may 
pass  in  front  of  it.  Much  less  commonly 
the  main  trunk  or  all  its  branches  will  be 
found  to  lie  in  front  of  the  nerve. 

Occasionally  the  thyroid  arteries  are  re- 
inforced by  an  additional  artery,  the  thy- 
roidca  ima.  This,  when  present,  is  usu- 
ally derived  from  the  innominate  artery. 
It  may  come,  however,  from  the  aorta  or 
the  common  carotid,  or  some  other  neigh- 
boring vessel.  It  runs  upwards  and  in- 
wards, and  is  distributed  to  the  lower  part 
of  the  gland. 

All  the  thyroid  arteries  communicate 
freely  with  each  other.  When  one  is 
small  or  absent  the  others  are  usually  large 
in  inverse  proportion. 

It  is  worth  noting  that  nearly  all  the 
larger  branches  ramify  on  the  surface  of  the 
gland  just  beneath  the  capsule.  Only  the 
smaller  branches  penetrate  to  the  inte- 
rior. 

The  thyroid  veius  form  at  first  a  well- 
marked  plexus  on  the  surface  of  the  gland  ; 
this  plexus  lies  immediately  beneath  the 
thin  delicate  capsule  of  connective  tissue 
which  encloses  the  gland.  At  certain 
points  the  veins  penetrate  thiu  capauleand 


140 


SURGERT  OF  THE   THTROID. 


pass  off"  into  the  neighboring  trunks.  The 
chief  veins  thus  leaving  the  gland  are  the 
following  : 

The  superior  thyroid  vein  has  a  course 
similar  to  that  of  the  corresponding  artery  ; 
it  leaves  the  apex  of  the  superior  horn  and 
enters  the  internal  jugular  vein  a  little 
;ib  've  this  level.  The  superior  thyroid 
Veins  are  connected  with  each  other  by  a 
large  transverse  branch  running  along  the 
upper  border  of  the  isthmus. 

At  the  side  of  the  gland  is  sometimes 
found  a  single  vein,  the  middle  tliyroid, 
entering  the  internal  jugular  vein  ;  more 
often,  however,  the  place  of  this  vein  is 
taken  by  two  others  known  as  the  superior 
and  itiferior  accessory  thyroid  veins.  The 
superior  comes  from  the  upper  horn,  a 
little  below  the  apex  ;  the  inferior  comes 
from  the  lower  and  back  part  of  the  gland  ; 
both  pu-s  transver-ely  outwards  to  join 
the  internal  jugular. 

The  arrangement  of  the  veins  which 
leave  the  lower  border  of  the  gland  varies 
considerably  in  different  bodies.  From 
the  isthmus  and  inner  side  of  the  inferior 
horn  comes  a  vein  which  descends  more  or 
less  vertically  near  the  front  of  the  trachea  ; 
this  Kocher  gives  the  name  of  thyroidea 
ima.  On  the  left  side  it  enters  the  left 
innominate  vein  ;  on  the  right  it  joins 
either  the  right  or  left  innominate  vein. 
Frequently  this  vein  is  small  or  absent  on 
one  side  ;  frequently  the  two  veins  unite 
to  form  a  single  large  one,  which  descends 
vertically  in  front  of  the  trachea  until  it 
enters  the  left  innominate.  This  single 
vein  may  sometimes  be  regarded  as  an 
enlarged  right  thyroidea  ima,  that  of  the 
left  side  being  represented  merely  by  a 
small  accessory  vein.  At  the  lower  and 
outer  part  of  the  inferior  horn  there  is 
often  a  small  vein,  the  inferior  thyroid^ 
which  runs  obliquely  downwards  to  enter 
the  innominate  vein  at  its  commence- 
ment. 

When  the  thyroid  gland  is  normal  in 
size,  many  of  these  veins  may  seem  small 
and  unimportant.  But  when  it  is  much 
enlarged  by  disease  all  the  veins  become 
greatly  enlarged  and  distended,  and  assume 
considerable  importance,  especially  in  con- 
nection with  operative  procedures. 

Nerves. — These  come  from  the  middle 
and  inferior  ganglia  of  the  cervical  sym- 
pathetic and  from  the  inferior  laryngeal 
nerve.  It  is  said  that  a  branch  also  comes 
from  the  external  laryngeal  nerve. 


Lymphatica.  —  The  lymphatics  pass 
chiefly  into  the  glands  that  lie  in  front 
and  at  the  sides  of  the  trachea  ;  some  pass 
also  into  the  cervical  glands  at  the  sides  of 
the  thyroid  gland.  The  glands  first  affected 
in  malignant  disease  of  the  thyroid,  for 
example,  are  usually  very  deeply  seated 
behind  the  sternum,  where  they  cannot 
easily  be  seen  and  felt. 

Structure. — The  thyroid  gland  is  com- 
posed of  a  large  number  of  small  closed 
vesicles  supported  by  a  framework  of  con 
nective  tissue,  derived  from  and  continu- 
ous with  the  delicate  capsule  that  sur- 
rounds the  whole  organ. 

Lying  between  the  vesicles  are  masses 
of  round  cells  which  are  to  be  regarded  as 
undeveloped  vesicles.  They  are  more 
abundant  in  the  young  than  in  the  old, 
and  are  often  with  difficulty  distinguished 
from  cells  of  inflammatory  origin. 

The  vessels  are  lined  with  cubical  epi- 
thelium and  contain  the  well  known  col- 
loid material,  the  exact  use  of  which  is 
unknown  The  gland  has  no  duels,  but 
the  vesicles  communicate  with  the  lym- 
phatic vessels,  that  ramify  between  them, 
and  it  is  probably  through  the  medium  of 
the  lymphatics  that  the  colloid  secretion 
of  the  gland  reaches  the  general  circula- 
tion. 

The  existence  of  colloid  material  in  the 
lymphatic  vessels  can  easily  be  demon- 
strated. (  James  Berry,  "  Diseases  of  the 
Thyroid  Gland  and  their  Surgical  Treat- 
ment," 1901.) 

The  anatomy  of  the  thyroid  has  many 
times  been  described  from  a  topographical 
and  microscopical  point  of  view  by  as 
many  different  investigators. 

A  comparative  study  of  it  was  made  by 
Simon,  1844,  and  by  Brunier,  1859,  each 
of  whom  considered  and  described  the 
thyroid  gland  of  many  kinds  of  animals, 
including  amphibians. 

Creswell,  1877,  contributed  an  exhaus- 
tive study  of  the  minute  anatomy  of  the 
gland  in  the  dog. 

The  probable  branchial  origin  of  the 
thyroid  and  thymus  gland  has  been  sug- 
gested, but  never  proven. 

Regeneration  of  tissue  that  will  secrete 
thyroidine  is  considered  impossible;  once 
destroyed,  always  destroyed. 

Historical. — King  and  Cooper,  1S36, 
made  observations  on  the  thyroid  gland. 

Simon,  1844,  considered  the  compara- 
tive anatomy   of  the  thyroid  gland,   and 


SURGBRT  OF  THE   TllTROID. 


141 


Godart,  1S46,  described  the  Duvernoi 
muscle  of  the  thyroid  gland. 

Brunier,  1859,  wrote  an  interesting 
paper  on  the  comparative  anatomy  of  the 
thyroid,  and  Turner,  W.,  1859,  considered 
the  thyroid  glands  in  the  cetacea  (whale) 
and  gave  his  observations  on  the  relations 
of  the  thymus  to  the  thyroid  in  these  and 
certain  other  mammals. 

Qjiiintana,  A.,  1873,  reported  his  ob- 
servations on  the  anatomy  of  the  thyroid 
gland. 

Pflug,  1875,  made  a  comparative  study 
of  congenital  goitre. 

Cresswell,  E.,  1877,  contributed  to  the 
minute  anatomy  of  the  thyroid  gland  of 
the  dog. 

Quarterly  Journal,  London,  1877, 
published  a  paper  on  the  lymphatics  and 
parenchyma  of  the  thyroid  gland  of  the 
dog,  and  Baber,  1877  made  contributions 
to  the  minute  analomy  of  the  thyroid 
gland  of  the  dog. 

Proceedings  of  the  Royal  Society,  Lon- 
don, 1878,  contained  reports  of  further 
researches  on  the  minute  structure  of  the 
thyroid  gland,  as  did  the  Philadelphia 
Tr.,  London,  1881,  also. 

Clevenger,  S.  V.,  1881,  reported  on 
probable  branchial  origin  of  the  thyroid 
and  thymus  glands. 

Vincenzi,  L.,  1S85,  investigated  partial 
regeneration  of  the  thyroid  gland. 

Drobnik,  1886,  wrote  on  the  thyroid 
gland,  and  Piana,  G.  P.,  1886,  recorded 
his  observations  on  the  anatomy  of  the 
thyroid  gland. 

ISIalijeff,  N.,  1887,  mentions  the  pas- 
sage of  the  hypoglossus  nerve  through  the 
thyroid  gland. 

Herrmann  and  Tourneux,  1887,  studied 
the  development  of  the  thyroid. 

Mayer,  1888,  made  a  study  of  the 
goitre  and  thymus  in  amphibians. 

Sebileau,  1888,  made  notes  on  the 
capsule  and  the  ligaments  of  the  thyroid 
gland. 

Med.-Chir.  Tr.,  London,  1888,  consid- 
ered the  macroscopical  and  microscopical 
variations  of  the  human  thyroid  body. 

Ribbert,  1889,  and  Sanquirico,  1S89, 
believed  in  the  regeneration  of  the  thyroid 
gland. 

Gaudier,  IL  J.,  1891,  reported  on  the 
anatomy  of  the  thyroid  gland,  topography, 
and  descriptive  anatomy  of  the  original 
development,  with  a  record  of  a  series  of 
animal  operations. 


Prenant,  1893,  contributed  to  the  study 
of  the  development,  organic,  and  histology 
of  the  thyroid,  and  Brooks,  1893,  wrote 
on  the  origin  of  the  thyroid  gland. 

Abram,  J.  H.,  1896,  published  a  note 
on  the  development  and  the  anatomy  of 
the  thyroid  gland  in  disease. 

Welsh,  1897,  wrote  a  critical  anatomi- 
cal study  concerning  the  parathyroid 
glands,  and  Brian,  Eugene,  1898,  made 
researches,  anatomical  and  physiological, 
on  the  enervation  of  the  thyroid  gland. 

BIBLIOGRAPHY. 

King  and  Cooper.  Guy's  Hospital  Report, 
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Simon,  J.  Philadelphia,  Tr.,  London,  1844, 
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202  205. 

Panagiotades,  D.  De  glandulae  thyreoideae 
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Rokitansky,  C.     Wien,  1849. 

Schaffner.  Ztschr.  f.  rat.  med.,  Heidelburg, 
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Gallois,  E.  J.     Paris,  1851. 

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Turner,  W.  Tr.  Royal  Society,  Edinburgh, 
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Peremescho.  Centralb.  f.  d.  med.  wissensch., 
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Callender,  G.  W.  Proe.  Royal  Society,  Lon- 
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Muller,  W.  Jenaische  Ztschr.  f.  med.  u.  na- 
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Boechat,  P.  A.  Recherches  sur  la  structure 
normaledu  corps  thyroide,  Paris,  1873. 

Quintana,  A.  Anfiteatro  Anatomy,  Madrid, 
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Berger,  P.  Arch.  gen.  med.,  Paris,  1874,  xxiv, 
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Q^  J.  Micr.  Anat.,  London,  1S77,  xvii,  204- 
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Baber,  E.  C.  Philadelphia  Trans.,  Ivondon, 
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Zoja,  G.  Atti  d.  r.  Accad.  d.  Lincei  cl.  di  Sc. 
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Clevenger,  S.  V.  Science,  New  York,  iSBr, 
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77S- 

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1213-16. 

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x>.  391.  459.  4  Pl- 

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Association,  1899,  xxxiii,  1313-1320. 

PHYSIOLOGY    (1806-I903). 

The  function  of  the  thyroid  is  to  secrete 
thyroidine,  which  is  not  understood,  ex- 
cept that  its  absence  in  animal  life  results 
in  cretinism  or  myxedema. 


It  is  supposed  to  have  some  relation  to 
the  generative  organs  and  to  have  a  diu- 
retic influence,  but  this  is  very  indefinite. 

Its  effect  upon  the  cardiac  system  has 
been  known  for  many  years,  but  the 
vwdiis  operation  remains  unsolved. 

The  relation  of  thyroid  to  the  thymus 
gland  remains  in  doubt  ;  also  its  relation 
to  all  other  glands  and  their  functions. 

Historical. — Rush,  1806,  made  an  in- 
quiry into  the  functions  of  the  spleen, 
liver,  pancreas  and  thyroid  gland. 

Von  Vest,  1838,  and  jSIartyn,  1856,  en- 
deavored to  discover  the  functions  of  the 
thyroid  and  its  relation  to  other  organs. 

Porcher,  1880,  and  Lombard,  1883,  con- 
tributed essays  on  the  thyroid  and  its  re- 
lations to  the  functions  of  the  generative 
organs. 

Meuli,  18S3,  investigated  the  functions 
of  the  thyroid  with  experimental  physio- 
logical study,  and  Rogovitch,  1886,  a 
similar  investigation  on  the  physiology  of 
the  thyroid  gland  and  glands  related  to  it. 
Further  researches  into  the  functions  of 
the  thyroid  gland,  and  into  the  pathologi- 
cal state  produced  by  removal  of  same, 
was  published  in  the  Proceedings  of  the 
Royal  Society,  London,  18S6,  xl,  69. 

Freund,  1890,  considered  the  functions 
of  the  thyroid  and  its  relation  to  the  gene- 
rative organs. 

Gley,  1891,  reported  on  the  physiologi- 
cal effects  in  the  other  glands  into  which 
had  been  injected  the  extract  of  the  thy- 
roid gland,  and  Fenwick,  1891,  reported 
on  the  diuretic  action  of  fresh  thyroid 
juice. 

Sgobbo  and  Lamari,  1893,  reported  on 
the  functions  of  the  thyroid  gland  and  the 
physiological  effects  of  fresh  thyroid  juice 
in  myxedema. 

Putnam,  1894,  made  observations  on 
the  functions  of  the  thyroid  gland  and 
the  relation  of  its  enlargement  to  (xraves' 
disease  ;  also  remarks  on  the  therapeutic 
use  of  sheep  thyroids  and  olher  organic 
extracts. 

Gley,  1894,  discovered  certain  actions 
of  the  extract  of  thyroid  gland,  with  poi- 
son. 

Cadeac  et  Guinard  contributed  a  study 
on  the  functions  of  the  thyroid  body  in 
animals. 

Masoin,  1895,  contributed  a  study  of  the 
urinary  poison  in  determining  the  func- 
tions of  the  thyroid  body,  and  Morkotun, 
1895,  one  on  the  phosphate  of  albumen  in 


SURGERY  OF  THE    THYROID. 


143 


the  thyroid  gland  in  connection  with  the 
question  of  its  function,  while  Hutchinson, 
1896,  gave  one  on  the  chemistry  of  the 
thyroid  gland  and  the  nature  of  its  active 
constituent. 

Warren,  1S96,  reported  on  the  present 
knowledge  of  the  interstitial  secretion  of 
the  thyroid  gland,  and  Gley,  1897,  re- 
marked on  the  influence  of  internal  secre- 
tion of  thyroid  gland  on  the  other  organs. 

Tourneux  et  Verdun,  1897,  wrote  on 
the  early  development  of  the  thyroid  and 
its  functions,  and  Comte,  1898,  contributed 
a  study  on  the  functions  of  the  thyroid  and 
its  relation  to  other  organs,  in  which  he 
considered  the  indirect  influences  of  fer- 
ments on  the  thyroid  gland. 

Guinard,  1899,  wrote  on  the  cardio  vas- 
cular actions  due  to  goitre. 

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144 


SURGERT  OF  THE   THYROID. 


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ANOMALIES     (1838-I9O3). 

The  thyroid  gland  may  be  represented 
by  one  or  more  lobes,  with  or  without  an 
isthmus.  If  but  one  lobe  it  may  vary  in 
size,   shape   and    location.     If  more   than 


one  lobe  they  may  all  be  upon  one  side  of 
the  neck,  usually  upon  the  left,  and  vary 
in  size.  If  more  than  one  lobe,  all  are 
influenced,  as  a  rule,  sooner  or  later,  in 
tlie  same  way  at  the  same  time  or  at  differ- 
ent times,  if  one  lobe  becomes  cystic,  all 
become  so.  If  one  becomes  hypertrophied, 
all  become  so.  The  exception  to  this  rule 
is  rare.  All  may  and  should  be  removed 
when  diseased,  except  a  small  portion  of 
the  most  normal  lobe. 

All  vertebrates  are  subject  to  the  same 
laws  concerning  abnormalities  and  disease 
of  the  thyroid  gland.  It  may  vary  in  shape, 
size  and  location,  single,  multiple,  fixed 
or  wandering. 

Historical . — Lingi,  1830,  mentioned  a 
case  of  substernal  thyroid  gland,  while 
Sestie,  1846,  described  one  situated  behind 
the  scapula. 

Curling,  1850,  observed  two  cases  in 
which  the  thyroid  glands  were  absent, 
with  symmetrical  swellings  of  fat  tissue 
at  the  sides  of  the  neck.  There  was  also 
defective  cerebral  development, 

Kadyi,  1S79,  reported  a  case  of  acces- 
sory thyroid  glands  situated  above  the 
hyoid  bone,  and  Gow,  1883,  one  in  which 
there  was  total  absence  of  the  left  lobe. 

Pollard,  1885,  recorded  a  case  of  an 
accessory  thyroid  gland  with  an  intra- 
cystic  papilloma,  and  D'  Ajutolo,  1890, 
one  in  which  there  was  struma, 

Warren,  1892,  recorded  a  case  of  en- 
larged accessory  thyroid  gland  at  the  base 
of  the  tongue. 

BIBLIOGRAPHY. 

Gassan,  A.  S.  Goitre  hereditaire  et  dans  un 
rapport  singulier  avec  in  phthisic  pulmonaire. 
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Lingi,  C.     Monachii,  1830. 

Campbell,  A.  Observations  on  the  Congenital 
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Sestie.  Bull.  soc.  anat.,  Paris,  1832,  2  ed., 
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Besnard,  A.  Ein  beitrag  zu  struma  congenita. 
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Curling,  T.  B.  Med.  Chir.  Tr.,  London,  1850, 
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SURGERY  OF  THE   THTROTD. 


145 


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Shurley,  E    L.     Med.  News,  October  11,  1902. 


GENERAL    GOITRE. 


Causes. — The  causes  of  goitre  are  not 
definitely  known,  but  they  are  supposed 
to  be  many,  as  follows,  in  the  order  of 
their  supposed  frequency:  (i)  Heredity, 
(3)  mental  worry,  (3)  water,  (4)  iron 
pyretes,  (5)  earthy  salts,  (6)  nephritis, 
(7)  malaria,  (8)  acute  infectious  diseases, 
(9)  hemorrhage,  (10)  parasites,  (vegetable 
and  animal),  (11)  bacill. 

Hereditary  lufiucnccs. — The  prepon- 
derance of  evidence  is  that  this  is  the 
greatest  causative  factor  in  the  production 
of  enlargement  of  the  thyroid  gland,  borne 
out  by  the  fact  that  many  cases  of  con- 
genital goitre  have  been  reported. 

Mental  Worry,  although  believed  by 
some  to  be  a  cause,  has  not  been  well  sub- 
stantiated. 

Water  from  fresh  water  sand-stone  is 
claimed  by  Waters  to  be  conducive  to 
abnormal  growth  of  the  thyroid  gland, 
while  he  claims  that  water  from  salt  water 
sand-stone  is  not  conducive  to  their  de- 
velopment. 

Animals  have  goitre  by  drinking  water 
free  from  bacteria  found  in  water  which 
victims  had  drank. 

Iron  Pyrites  in  water  was  supposed  by 
Paracelsus  (sixteenth  and  seventeenth  cen- 
tury) to  be  a  cause  of  goitre,  but  this  has 
never  been  proven. 

Earthy  Salts,  such  as  silica,  aluminum, 
lime,  magnesia,  iron  and  manganese,  are 
supposed  to  be  causes  of  goitre  found  in 
the  clay  eaters  of  Bolivia.  The  disease  is 
prevalent  among  them. 

Goitre  is  also  found  to  prevail  in  the 
carboniferous  lime  districts. 

Neprhritis  from  any  cause  may  induce 
it,  and  when  due  to  nephritis  is  of  rapid 
development  as  a  rule. 

Jlen/orrhaoc  into  the  gland  as  a  result 
of  rupture  of  a  blood-vesi^el  from  any  cause 
will  also  excite  an  abnormal  development 
of  the  thyroid  gland. 

Thyroiditis  is  rare,  and  when  present 
follows  an  operation  or  injury,  or  local  or 
general  infection  from  any  cause. 

Parasites.  —  (i)  Echinococcus,  most 
common;  (2)  cysticercus,  rare;  (3)  para- 
gonimus  westermani,  rare. 


146 


SURGERY  OF  THE   THYROID. 


Bacilli. — (i)  Coli  commune,  rare;  (2) 
pneumonococci,  rare ;  (3)  typhoid,  rare; 
(4)  tuberculosis,  not  common;  (5)  micro- 
organisms of  selective  type  waters,  (?). 

lUHLIOGRAPHY. 

Starr,  L.  Philadelphia  Medical  Times,  1878, 
viii,  344. 

Marchant,  G.  Thyroidite  a  Pneumococoques. 
Arch.  International  de  Laryngol.,  Paris,  1891, 
iv,  129-132. 

Gerard  -  Marchant.  Thyroidite  Pnruntococo 
viics,  Coner.  Franc,  de  Chir.,  Proc.  verb.,  Paris, 
1891,  V,  268  270. 

Jeanselme  and  Navarro.  Thyroidite  a  Sfref- 
toroques.  Rev.  Gen,  de  Clin,  et  Terap  ,  Pans, 
1895,  ix,  pt.  2,  149-152. 

Heddacus.  Ein  fall  von  Acuter  Strumitis  durch 
Diplococctis  Frankcl  Weichselbaum  mit  Secun- 
darer  Metastat  Pneumonie.  Munchen  Med. 
Woch.,  1896,  xliii,  492  494. 

LaxarefF,  E.  Staphylomycose.  Ejened.,  St. 
Petersburg,  1900,  vii,  593  596. 

Actite  may  be  solid  or  cystic,  containing 
pus  or  blood.  May  be  slow  or  sudden,  in 
either  event  varying  in  size,  shape  and 
position,  single  or  multiple,  fixed  or  mov- 
able. 

Chronic  may  be  solid  or  cystic,  contain- 
ing blood,  pus  or  serum.  May  vary  in 
size,  shape,  location  and  degree  of  con- 
sistency, and  be  fixed  or  movable,  single 
or  multip'e. 

Atrophy  is  infrequent  and  usually  results 
from  tumor  pressure  or  the  internal  use  of 
iodine. 

Amyloid  degeneration  usually  attacks 
hypertrophied  tissue,  and  involves  the 
epithelium  and  vessels,  producing  great 
vascularity,  and  is  intimately  associated 
with  the  lymphatics. 

There  is  albuminous  colloid  material, 
the  contained  active  principle  of  which  is 
iodine. 

Results.  —  (i)  Insanity;  (3)  death — 
rupture,  hemorrhage;  infection,  sudden 
development. 

Insanity  may  be  due  to  pressure  upon 
the  carotids,  with  its  cerebral  anemia. 

Riipturc  may  be  into  trachea,  pleural 
cavity  and  subsequently  into  the  lung. 
Empyemia  may  ensue. 

IIcvio)-rhagc. — One  or  more  blood- ves- 
sels may  rupture,  with  hemorrhage  into 
the  capsule  sufficient  to  produce  death  from 
pressure,  or  the  blood  may  escape  into  the 
trachea,  pleural  cavity  or  lung,  or  both, 
or  it  may  be  subcutaneous  or  intramus- 
cular. 

Sudden  development  usually  results  in 
death. 


riemmorrhage  may  result  in  infection 
and  abscess. 

ETIOLOGY — B I BLIOGRAPH  Y. 

Dorr.  J.  Facts  Concerning  Goitre  as  it  Occurs 
In  the  Towns  of  Camden,  Sandgate  and  Chester 
Within  the  States  of  New  York  and  Vermont, 
and  Conjectures  Concerning  its  Cause.  Med. 
Repos.,  New  York,  1807,  iv,  141-144. 

Spalding,  L.  Further  Information  on  Goitre. 
Med.  Reposit.,  New  York,  1808, xi,  3-6. 

Si-hade,  F.  A.  De  struma  aetiologia  et  diag- 
nosi  nonnulla.     Lipsiae,  1809 

Paris,  ].  L.  Dissertation  sur  les  maladies  du 
corps  thyroide,  Paris,  1826. 

Chevalier,  U.  Memoire  sur  la  thyroidite  Rec 
de  mem  de  med  mil  ,  Paris,  1830,  xxix,  323-337. 

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H7 


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Rampold.  Noch  einiges  ueber  die  ursachen 
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Gross,  T.  Ueber  die  ursachen  des  endemis- 
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Falck,  C.  P.  De  thyreophyriate  endemico  per 
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et  variquex  observes  dans  le  departement  du 
Puy-de-Dome.  Rev.  med.  chir.,  Paris,  1852,  xii, 
328-334. 

Nivet,  V.  Note  sur  les  goitres  estival  epidem- 
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de  chir.,  Paris,  1852-3,  iii,  437,  493. 

Vingtrinier.  Du  goitre  endemique  dans  le 
departement  de  la  Seine-Inferieure  et  de  I'eti- 
ologie  de  cette  mala  die.     Rouen,  1854. 

Vingtrinier.  Du  goitre  endemique  dans  le 
departement  de  la  Seine-Iuferieure  reflexion  "sur 
I'etiologie  de  cette  maladie.  Ann.  d.  hyg.,  Paris, 
'853,  i,  380;   185 1,  2s,  i,  32. 

Filhol.  Goitre  endemique  rapport  sur  le  con- 
cours  de  1855  presente  au  nom  d'une  commission 
a  I'academie  imperiale  des  science  de  Toulouse 
(Extrait  des  memoires  de  I'academie).  Jour,  de 
med.  chir.  et  pharm.  de  Toulouse,  1855,  vii,  270, 
306,  336. 

Fleury.  Memoire  sur  une  epidemia  de  goitre 
qui  a  regne  a  Clermont  pondant  I'ete  de  i860  sur 
les  soldats  de  la  garnison.  Gaz.  med.,  1861,  xvi, 
510  512. 

Communication  sur  fe  goitre  endemique  des 
rivres  de  la  Seine.     Caen,  1862. 

HofTmann.  Der  epidemische  kropf.  Aerztl. 
int.-bl.,  Munchen,  186.',  ix,  62. 

Morelle.  Nole  sur  une  epidemie  de  goitre 
observee  an  8  de  ligne  en  garnison  a  Clermont- 
Ferrand  et  a  Riom.  Rec.  de  med.  mem.  mil., 
Paris,  1862,  viii,  438  440. 

Rapport  sur  une  epidemie  de  goitre  observee 
dans  la  garnison  de  Colmar  pendant  les  mois  de 
Janvier  et  Fevrier,  1863.   I!)id.,  1863,  x,  180,  271. 

De  I'undemie  goitreuse  des  rives  de  la  Seine. 
Long.  med.  de  France,  Paris,  1863,  i,  290-298. 
I  pi. 


Hcdoin.  Endemo-epidemique  de  goitre  ob- 
servee sur  la  garnison  d'Embrum  (Hautes  Al- 
pres)  de  Janvier  a  mars    1863.     Ibid.,  465-488. 

Haberkorn,  G.     Strassbourg,  1864. 

Weisse,  J.  F.  Ueber  den  endemischen  kropf 
in  government  Oionetz.  St.  Petersburg  med. 
ztschr.,  1864,  vii,  389-391. 

Sallard,  A.  Essai  sur  le  goitre  epidemique. 
Paris,  1865. 

Worbe.  Epidemie  de  goitre  aigu.  Rer.  de 
mem.  de  med.  mil.,  Paris,  1867,  xviii,  104-106. 

Relation  de  I'epidemie  de  goitre  qui  a  regne 
dans  le  45  regiment  d'infanterie  de  ligne  en  1866 
precedee  d'une  etude  topographique  du  departe- 
ment de  la  Haute  Savoie  et  de  la  ville  d'Anneey 
en  particulier.     Ibid  ,  1867,  xix,  273.  369. 

Thibaud,  L.  Du  goitre  epidemique,  Paris, 
1867. 

Mulier.  Du  goitre  epidemique  dans  la  garni- 
son de  Neuf  Brisach,  1869  7o-  Ibid.,  1871,  xxvi, 
24-!  255. 

Nivet,  V.  Etude  sur  le  goitre  epidemique. 
Paris,  1873. 

Plot,  C.    Du  goitre  endemique.    Paris,  1873. 

Voutier,  J.  F.  Du  Goitre  endemique  au  point 
de  vue  symdtomatologique  etiologique  diagnos- 
tique  et  curatif.     Montpeilier,  1874. 

Michaud.  Observations  sur  le  goitre  epidem- 
ique de  la  garnison  de  Saint  Etienne  (1873).  Gaz. 
med.  de  Paris,  1874,  i"'  I7>  ^7- 

Labit,  F.  A.     Montpeilier,  1877. 

Nivet,  V.  Gazette  hebed.  de  med.,  Paris, 
1874,  xi,  55- 

Cespedes.  El  bocio  endemico  en  la  republica 
Argentina.  Siglo  med.,  Madrid,  1876,  xxiii, 
642  646. 

Gaillard,  A.  Reflexions  sur  une  epinemie  de 
goitre  curbenue  a  la  caserne  du  palais  des  Papes 
a  Avignon  (1877).     Montpeilier,  1878. 

A  propos  de  la  genese  taenoide  et  de  ses  rap- 
ports avec  I'endemie  goitreuse.  Gaz.  med.  de 
I'Algerie,  Algeria.     Paris,  1877,  xxii,  29. 

Baelen,  B.  Genese  taenoide  du  goitre  endem- 
ique. Rec.  d.  trav.  soc.  med  d'Indre  et  Loire, 
1877.     Tours,  1878,  Ixxiv,  71  75. 

Chaligin,  K.  O  zobie  voobtche  i  obe  endemis- 
cheskome  iobie  ve  kokanie  ve  osobennoist.  (On 
Goitre)  Voyenno  Med.  Jour  St.  Petersb.,  1878, 
cxxxii,  50,  115,  179,  cxxxiii,  177. 

Urzica,  J.  B.  Etude  sur  le  goitre  aigu  a  propos 
de  I'epidemie  suryenue  au  mois  de  mai  1878  dans 
13  12  regiment  de  ligne  en  garnison  a  Lodeve. 
Montpeilier,  1878. 

Fereol.  Disparition  spontanee  d'un  goitre 
epidemique  coheredilaire  chcz  un  phthisitiue  de 
23  ans.  Ann.  d.  mal.  de  I'oreille  et  du  larynx, 
Paris,  1879,  v,  95. 

Viry  and  Richard.  De  la  nature  du  goitre 
epidemique  a  propos  de  I'epidemie  qui  a  sevi  sur 
les  troupes  de  la  garnison  de  Belfort  en.  1881. 
Gaz.  hebd.  de  med  ,  Paris,  1881,  xviii,  457,  480. 

Czerhicki,  A.  De  la  non  -  transmissable  du 
guitre  aigu  epideinique.  Gaz.  hebd.  de  med., 
Paris,  i88r,  xviii,  611. 

Krishaber.  Du  goitre  epidemique  revue  gen- 
erale.  Ann.  de  mal.  de  I'oreille  et  du  larynx, 
Paris,  1882,  viii,  125  133. 

Low,  R.  B.  TheEtialogy  of  Endemic  Goitre. 
British  Med.  Journal,  London,  1882,  i. 

Sloan,  A.  E.  Endemic  Goitre  in  Wishaw  and 
Neighborhood.  Edinburg  Med.  Journal,  1883-4, 
XXX,  30-37. 


ISO 


SURGER7'  OF  THE    THTROID. 


Bircher,  H.  Der  endemischer  kropf  und  seine 
beziehungen  zur  taubstummheit  und  zum  cretin- 
isms.    Basel,  1883. 

Giles,  G.  M.  Notes  on  Endemic  Goitre:  Its 
Etiology  and  Treatment.  Indian  Med  Journal, 
Calcutta,  1888,  V,  467,  515. 

Hacon.  Endemic  Disease  of  New  Zealand; 
Goitre  Endemic  on  the  Canterbury  Plains  about 
Christchurch.  Nev  Zealand  Med.  Journal. 
Dunedin,  1888-9,  I'l  ^44- 

Fratini,  F.  LI  gozzo  endemico  e  le  acque  cal- 
careo-magnesiache.     Feltre,  1889. 

Lustig.  Ueber  die  Aetiologie  des  Fpidemis- 
chen  Kropfes.  Verhandl.  d.  X  International 
Med.  Congress,  1890,  Berlin,  1891,  ii,  33  abth., 
99-104. 

Charvot.  Etude  clinique  sur  les  goitres  spora- 
diques  infectieux.  Rev.  de  chir.,  Paris,  1890,  x, 
701  730. 

M'Kenzie,  D.  Endemic  Goitre  and  its  Occur- 
rence in  Lanarkshire,  with  Some  Observations 
on  the  Pathology  of  the  Disease.  Glasgow  Med. 
Journal,  1890.  li,  15  24. 

Armaingaud,  A.  Sur  I'opportunitie  de  rap- 
peler  I'attention  sur  la  question  du  goitre  endem- 
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tique.     Toulouse,  1891. 

Sananelli.  Le  condizioni  attuali  delle  endemie 
gozzigene  in  Italia.  Gior.  d.  r.  soc.  Ital.  d'ig., 
Miiano,  1895,  xvii,  173  192,  i  ch. 

Hupenden,  F.  O.  H.  Die  aflfectionibus  in- 
flammatoris  glandulae  thyreoidea,  Heidelbergae, 
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Conrad,  J.  G.  H.  Commentatio  de  cyanche 
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Plieninger.  Entzundung  und  vereiterung  der 
schilddruse  thyreoadenitis  therophyma  ac  utum 
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burtsh.,  Stuttg.,  1854,  vii,  56  59. 

Bauchet,  L.  J.  Ue  la  thyroidite  (goitre  aigue) 
et  du  goitre  enflamme  (goitre  chroniqiie  en- 
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19.  52.  75.  9^- 

Martinache,  N.  De  I'inflammation  aigue  du 
corps  thyroide  ou  thyroidite,  Paris,  1861. 

Geschichte  (zur)  des  acuten  kropfs  in  den 
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Ludwig.  Ein  fall  von  acutem  kropf.  Arch. 
d.  heilk.,  Leipz  ,  1873,  xiv,  94  96. 

Detrieux,  J.  G.  Considerations  sur  la  thy- 
roidiet  ou  inflammation  aigue  du  corps  thyroide, 
Paris,  1879. 

Knight,  F.  A.  Acute  Idiopathic  Inflammation 
of  the  Normal  Thyroid  Gland.  Arch,  Laryngol., 
New  York,  1880,  i,  155. 

Simon,  M.  D.  Contribution  a  I'etude  de  I'in- 
flammation  aigue  de  la  glande  thyroide,  Paris, 
1880. 

Gaiter,  H.  De  la  thyroidite  aigue  primitive 
etat  actuel  de  la  question,  Paris,  1881. 

Lane",  C.  L.  Acute  Inflammation  of  the  Thy- 
roid. Gland.  Med.  Record,  New  York,  1885, 
xxviii,  65. 

Kohn,  A.  Ueber  strumitis  und  thyroiditis. 
Allg.  Wien.  medical  ztg.,  1885,  xxx,  153,  162,  188, 
216,  244,  258. 

Zoulovitch,  E.  De  la  thyroidite  aigue  rheu- 
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Ricklin,  F.  Observations  de  thyroidite  aigue, 
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Koranyi.  Inflammation  of  the  Thyroid  Gland. 
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Brunner,  C.  Ein  fall  von  acut  eiteriger  stru- 
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xxii,  298-307. 

Given,  J  O.  M.  Acute  Thyroiditis.  Lancet, 
London,  1892,  ii,  935. 

Ungar,  U.  Case  of  Acute  Thyroiditis,  Or- 
vosi Hetil,  Budapest,  1892,  xxxvi,  413. 

Chantemesse  et  Marie.  Les  glandes  parathy- 
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Medical  d.  hop.  y.  Pari'^,  18L3,  x,  202  204. 

Minutilla,  S.  Un  caso  di  I'iroidite  acuta  idio- 
patica.  Atti  d.  r.  accad.  di  Sc.  Med.  in  Palermo 
(1891),  1895,  224-230. 

Munk,  j.  Case  of  Thyroiditis.  Gyogyaszat, 
Budapest,  1895,  xxxv,  410. 

Mytrind,  11.  Thyroiditis  acuta  simplex,  llosp. 
tid.,  Kjobenh.,  1895.  4  •■'  i'>  11811197. 

Jeamseime,  E.  Thyro'dites  et  strumites  in- 
fectieuses,  Gaz  d.  hop.,  Paris,  1895,  Ixviii,  133- 
142. 

Gailliard.  Un  cas  de  thyroidite  aigue  terminee 
par  resolution.  Bull  ct  mem.  Society  Medical  d. 
hop.  Paris,  1895,  ''^''>  507"509 

Tailhefer,  E.  Variete  tres  rare  de  thyroidite 
chronique.  Gazzette  hebd.  de  Medical,  Paris, 
1897,  ii,  145. 

llalipre,  A.  Congestion  thyroidienne  chez  un 
Jeune  homnie  traitement  iodure  suivi  du  traite- 
ment  thyroidien,  Normandie  medical,  Rouer, 
1897,  xii,  517  527. 

Findlayson,  D.  W.  A  Fatal  Case  of  Acute 
Thyroiditis.  American  Journal  Surgery  and 
Gynecology,  St.  Louis,  1898  9,  x',  67. 

Ceci,  A.  Strumite  acuta  del  lobu  sinistro  della 
Tiroide,  Riforma  medical,  Palermo,  1900,  i,  79. 

Gozzo  vascolare  esoftalmico  di  1  hb  •  sini-tro 
e  dell'istmo  della  Tiroide,  Riform  i  medical,  Pa- 
lermo, 1900,  i,  65-66 

Stamm,  G.  Thyreoiditis  acuta  (idiopathica). 
Arch.  f.  kinderh.,  Stuttgart,  1900,  xxviii,  228- 
230. 

Anatomia  patologira  dell.  Apparecchio  Tiroi- 
deo,  Gazz.  d.  0?p.,  Miiano,  1900,  xxi,  265  266. 

THVKOIDITIS. 

Historical. — Gaucher,  1S42,  recorded  a 
case  of  hypertrophied  thyroid  gland  pro- 
ducing asphyxia. 

Foote,  1852,  presented  an  address  on 
"  Goitre  in  Grenada." 

Bounet,  1855,  reported  a  case  of  simple 
goitre  producing  suffocation. 

Simpson,  1855,  recorded  a  case  of  goitre 
in  an  infant,  and  Keiller,  1855,  a  congeni- 
tal goitre. 

Blackman,  1858,  observed  a  case  of  en- 
larged thyroid  gland  producing  suffoca- 
tion, and  Edwards,  1858,  one  producing 
fatality. 

Danyau,  1861,  reported  a  case  of  goitre 
found  in  a  fetus. 

Mitchell,  1862,  mentioned  the  "  Niths- 
dale  Neck"  (goitre),  in  Scotland. 


SURGER2'  OF  THE   TIITROID. 


151 


Baillarger,  1S63,  observed  goitre  in  ani- 
mals, and  recorded  some  interesting  facts. 

Potain,  1863,  reported  a  case  of  goitre 
with  dilatation  of  the  breast  and  pulmon- 
ary apoplexy. 

Simpson,  1866,  reported  a  case  of  con- 
genital goitre. 

Rey,  1873,  reported  a  case  of  lateral 
compression  of  the  trachea,  due  to  enlarge- 
ment of  the  thyroid  gland.  He  also  re- 
corded a  case  of  double  lateral  compression 
causing  suffocation. 

Bergeret,  1873,  wrote  on  apoplectic 
vertigo  due  to  strangulation  and  suffoca- 
tion from  goitre. 

Marsh,  1874,  recorded  two  cases  of 
goitre  in  young  children. 

Brochin,  1874,  reported  a  case  of  glos- 
sitis and  suffocation  due  to  goitre. 

Tait,  Lawson,  1875,  recorded  a  case  of 
enlargement  of  the  thyroid  gland  in  preg- 
nancy. 

Starr,  1878,  recorded  a  case  of  sponta- 
neous cure  of  goitre  following  an  attack 
of  typhoid  fever. 

Duplay,  1879,  mentioned  a  case  of 
retro-sternal  goitre  causing  suffocation. 

Bennett,  1880,  mentioned  a  case  of  acute 
menstrual  goitre. 

Mackenzie,  1881,  recorded  a  case  of 
fibroid  goitre  causing  paralysis  of  both 
recurrent  laryngeal  nerves  and  giving  rise 
to  aphonia  and  dysphagia. 

Chalmers,  1883,  mentioned  a  case  of 
congenital  and  hereditary  goitre. 

Humrichouse,  1890,  recorded  two  cases 
of  suffocation  due  to  goitre. 

JoftVo,  1892,  mentioned  a  case  of  goitre 
associated  with  pregnancy, and  PyeSmith, 
1893,  reported  a  case  of  congenital  en- 
largement of  the  thyroid. 

Holmes,  1895,  wrote  on  sporadic  goitre, 
its  variations  and  the  results  of  modern 
treatment. 

Hodenpyl,  1896,  observed  an  enormous 
goitre  in  a  white  mouse. 

Goris,  1897,  mentioned  a  case  of  retro- 
sternal goitre. 

De  Sante,  1898,  recorded  a  case  where 
an  enlarged  thyroid  gland  produced  pres- 
sure upon  the  recurrent  laryngeal  nerve. 

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154 


SURGER7-  OF  THE   THTROID. 


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SIMPLE  GOITRE. 

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SPASM    FROM   PRESSURE. 

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GOITRE  IN  DOMESTICATED  ANIMALS. 

Baillarger.  Compt.  rend.  acad.  d.  sc,  Paris, 
1862,  Iv,  475-477. 

Foot,  A.  W.     (N.  P.),  1870. 

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Hodenpyl,  E.  Proc.  New  York  Path.  Society, 
(1895),  1896,  18. 

EXOPHTHALMIC   GOITRE   (1761-I9O4). 

IVIore  frequent  in  female,  seldom  before 
puberty,  rare  after  middle  life,  and  ap- 
pears during  sexual  activity. 

Independent  of  other  forms  of  goitre. 
Pathology  not  known.  Almost  always 
bilateral.     Eyes  do  not  always  protrude. 

Symptoms  and  diagnosis  difficult  if  eyes 
do  not  protrude  in  early  stage,  easy  in  ad- 
vanced stage. 

Epiphora  in  exophthalmic  goitre  is  con- 
sidered by  Berger  (^Archives  of  Ophthal- 
mology^ New  York,  September,  1903). 
He  reports  having  observed  a  secretory 
neurosis  of  the  lachrymal  glands  similar  to 
the  other  secretory  neuroses  of  exophthal- 
mic goitre.  He  rejects  the  mechanical 
explanations  that  have  been  offered.  If 
this  theory  is  correct,  of  course,  sounds 
and  astringent  injections  are  useless.  The 
best  treatment  is  that  which  relieves  the 
general  symptoms  as  well  as  the  epiphora, 
though  in  otistinate  cases  perhaps  the  in- 
ternal use  of  atropine  or  local  instillations 
of  cocaine  might  be  tried.  For  any  an- 
noying dryness  of  the  ball  he  has  suggested 
the  instillation  of  sterile  salt  solution, 
which  has  been  employed  with  good  re- 
sults {you")ial  American  Medical  Asso- 
ciation) . 

Exophthalmus,  tachycardia  and  goitre 
are  the  three  most  important  symptoms. 
Tedeschi  has  established  that  a  lesion  of 
tjie  restiform  body  is  able  to  induce  in 
rabbits  and  dogs  not  only  exophthalmos 
and  tachycardia,  but  a  generalized  tremor, 
polyuria,  glycosuria  and  salivation.  This 
occurred  invariably  in  his  experimental 
research  when  the  lesion  was  in  the  an- 
terior portion  of  the  restiform  body, 
directly  behind  the  auditory  tubercle. 

Usually  there  is  great  nervousness  ;  diar- 
rhea, glycosuria  and  skin  pigmentation 
may  one  or  all  be  present,  but  are  not 
constant  or  universal. 

Hofbauer  has  studied  the  respiratory 
curves  in  several  cases  of  exophthalmic 
goitre  which  showed  marked  disturbances 
of  respiration.  Some  of  these  disturbances 
are  of  a  secondary  nature,  being  due   to 


SURGBRT  OF  THE    THTROID. 


155 


cardiac  complications,  pressure  on  the  tra- 
chea, bronchitis,  etc.  But  in  other  cases 
the  respiratory  changes  cannot  be  attri- 
buted to  those  causes,  being  directly  due 
to  the  perverted  function  of  the  thyroid 
gland.  The  changes  may  be  more  or  less 
permanent,  and  are  characterized  by  flat- 
tening of  the  respiratory  curve,  lengthen- 
ing of  inspiration  and  expiration,  and 
irregularities  in  height  and  form  of  curve. 
Accidental  disturbances  may  occur  in  the 
form  of  deepened  respirations,  rapid  in- 
spirations and  expirations,  and  respiratory 
pause.  {^American  Medicine,  October  3, 
1903,  p.  564.) 

Rapid  pulse  following  removal  of  a 
thyroid  gland  is  probably  due  to  rapid 
absorption  of  thyroidine  in  the  process  of 
repair.  Pulse  will  sometimes  reach  150 
per  minute,  but  subsides  to  80,  90  or  100 
at  the  end  of  one  hundred  hours. 

Stridor,  dyspnea,  dysphagia,  rapid 
growth,  emaciation,  fever,  infection  or 
syncope,  one  or  all,  may  be  present. 

It  was  recognized  by  Morgagni  in  1761  ; 
C.  H.  Parry,  an  Englishman,  in  1786; 
Graves,  1835,  and  Basedow  (German), 
1840. 

The  English  call  it  Graves'  disease,  the 
Germans  Basedow's  disea'^e,  and  the  Ital- 
ians morbo  di  Flagani,  after  an  Italian  by 
the  name  of  Flagani,  who  was  an  early 
observer  of  the  disease.  The  proper  name 
should  be  exophthalmic  goitre. 

It  was  first  believed  to  be  due  to  anemia, 
which  suggested  the  use  of  quinine. 

Treatment. — But  few  medicaments,  if 
any,  are  even  palliative  ;  none  curative. 
Sodium  phosphate,  salicylic  acid,  thy- 
mus, and  suprarenal  gland  are  most  pop- 
ular. 

IMany  cases  of  acute  goitre,  whether 
simple  or  exophthalmic,  will  disappear 
after  colon  flushing  or  change  of  residence. 
This  is  especially  so  when  due  to  Plasmo- 
dium malarijE  and  septic  matter  found  in 
drinking  water  and  air. 

Surgery  offers  the  only  means  of  relief. 

Tillaux,  1880,  was  the  first  to  operate. 
Manheimer,  1894,  collected  40  cases  oper- 
ated upon.  Starr  has  collected  190  cases 
operated  upon  before  1895 — partial  re- 
moval of  the  gland,  and  a  few  ligations  of 
the  thyroid  artery  ;  23  died  immediately, 
mortality  12  per  cent. 

Sargo  reports  174  operations  from  18S4- 
1896;  2  result  not  known;  27  (iS  2  per 
cent.)  much  improved;   62  (36  per  cent.) 


distinctly  improved;  48  (27.9  percent.) 
cured;  11  (6.4  per  cent.)  not  improved  or 
made  worse;  24  (13.9  per  cent.)  died 
soon  after  the  operation. 

Ord  and  Mackenzie  report  33  opera- 
tions; 8  died,  5  recovered,  9  almost  com- 
plete recovery,  9  considerable  improve- 
ment, I  slight  improvement,  i  in  statu 
quo. 

Williamson  records  24;  6  fatal,  5  com- 
plete recovery,  2  almost  complete  recovery, 
4  considerable  improvement,  3  slight  im- 
provement, 3  static  quo,  and  i  alive  but 
condition  unknown. 

Kocher  (Mitteilungen  a.  d.  Grenzge- 
bieten,  Jena,  ix,  142,  1902)  gives  1,432 
titles  and  reports  93  operations  for  exoph- 
thalmic goitre  since  18S7;  50  of  these 
were  of  his  own  cases ;  45  of  his  cases  are 
permanently  cured,  8  improved,  2  slightly 
so,  and  4  died.  Of  the  93.  30  were  ex- 
tremely severe.  22  well  developed.  14  were 
cases  of  struma  vasculosa,  9  of  which  were 
operated,  3  pseudo  Basedow,  both  of 
which  were  operated  upon,  and  4  tran- 
sient. The  exophthalmos  vanished  com- 
pletely in  only  26  of  his  45  completely 
cured  cases,  In  the  others  it  persisted  in 
a  slight  degree,  probably  owing  to  the 
anatomic  alterations  induced  by  the  mor- 
bid process  previous  to  the  operation. 

Albert  Kocher  (Mitteilungen  a.  d. 
Grenzgebieten  der  Medizin  und  Chirur- 
gie,  1902,  ix,  Bd.  i  u.  2)  reports  93  cases 
of  exophthalmic  goitre  from  his  father's 
records,  of  which  59  were  operated  upon  ; 
45,  or  76  per  cent.,  cured  ;  10,  or  17.5  per 
cent.,  benefited;  4,  or  6.7  per  cent.,  died 
of  tetany  within  ten  hours  after  the  opera- 
tion. 

Ileydenrich,  1895,  collected  61  cases 
operated  upon,  Ehrhardt  collected  230 
operations;  68  per  cent,  cured  or  greatly 
improved,  vSchulz  collected  319  opera- 
tions ;  79  per  cent,  cured  or  greatly  im- 
proved. 

Coiiclnsio}is  for  Rxoplithalniic  Goitre. 
— Destroy  vascularization,  resect  smallest 
amount  of  tissue,  limit  blood  supj^ly  ;  liga- 
ture of  superior  arteries  ineffectual.  Eigi- 
tion  of  afferent  arteries  with  partial  ex- 
cision will  cure  a  few  of  the  severest  ca-es  ; 
remainder  of  gland  will  spontaneously 
subside, 

Kocher  says  that  "  iodine  will  aggra- 
vate, that  medicines  are  useless,  and  that 
operation  should  be  m  ide  wi  hout  waste 
of  time." 


156 


SURGERr  OF  THE   THYROID. 


Huntington  says  that  operation  is  the 
only  hope. 

Operations  of  selection  in  order  of  their 
supposed  value  are  : 

1.  Thyroidectomy — most  radical,  less 
mortality,  and  attended  by  better  results 
and  a  greater  number  of  cures. 

2.  Sympathectomy,  It><  value  is  yet  to 
be  determined  {by  a  great  number  of 
operations)  as  to  mortality,  efficacy  and 
per  cent,  of  cures. 

3.  Exothyropexy  is  the  easiest  and 
quickest,  results  not  so  good  or  great  in 
number.  ]\Iortality  higher,  with  more 
complications. 

4.  Ligation  of  arteries  least  desirable. 
Will  not  cure,  only  occasionally  palliative, 
and  the  goitre  will  recur. 

Thyroid  poisoning  following  thyroidec- 
tomy is  infrequent,  while  more  or  less  al- 
bumin and  granular  casts  have  been  found 
in  the  urine  after  operation  on  those  that 
have  died. 

Ether  is  prone  to  cause    pneumonia   in 
exophth.ilmos.      This    alone    should    indi 
cate  the  use  of  chloroform       A  few  should 
be  operated  upon   under   the   influence  of 
cocaine  subcutaneously  injected. 

Simple  Section  of  the  Sy?upathctic 
Nerve.  —  Jaboulay  performed  bilateral 
section  in  six  cases  and  the  unilateral 
operation  in  two  cases.  He  records  two 
cures,  five  improved  cases,  and  one  death, 
which  occurred  eighteen  months  after 
operation — a  mortality  of  12,5  percent. 
In  all  of  these  patients  the  exophthalmos 
was  influenced  favorably  after  the  first 
day;  the  thyroid  enlargement  disappeared 
slowly,  while  the  tachycardia  was  scarcely 
influenced  by  the  operation.  He  proposes 
that  in  cases  in  which  the  tachycardia  is 
pronounced  the  inferior  cervical  ganglion 
shall  be  excised. 

Balacesu  claims  that  simple  section  in- 
fluences the  exophthalmos  and  thyroid 
enlargement  but  little,  and  the  tachycardia 
not  at  all. 

Pean  pronounces  the  operation  resultless 
and  unnecessary.  He  advocates  thyroidec- 
tomy. 

Gayet  has  stated  that  simple  section 
powerfully  influences  the  triad  of  symp- 
toms, and  this  effect  is  permanent.  It 
must  be  remembered  that  (niyet's  article 
appeared  in  1896,  while  that  of  Balacesu 
was  published  in  1902. 

Stretching  of  the  Cervical  Sympathetic. 
— In  the  only  (Jaboulay's)  case  in  which 


this  operation  was  performed  the  tachy- 
cardia was  markedly  increa<5ed,  the  pulse 
ranging  from  110  to  130  two  weeks  after 
the  operation.  The  exophthalmos  and 
thyroid  enlargement  were  uninfluenced. 

Stretching'  of  the  Pnciimogastric  Nerve. 
— This  has  been  tried  by  Jaboulay  in  cases 
of  exophthalmic  goitre  with  severe  cough. 
It  is  said  to  arreat  the  laryngeal  spasms. 
This  procedure  must  be  regarded  as  dan- 
gerous and  without  curative  value. 

BIBLIOGRAPHY. 

Jaboulay.  Chirurgie  du  Grand  Sympathetique 
et  du  Corps  Thyroide,  1900.  p.  79. 

Balacesu.  Archiv.  fur  Klinische  Chirurgie, 
1902  (Vol.  67). 

jaboulay.     Lyon  Medicale,  April,  1898. 

Gayet,     Lyon  Medicale,  No.  30,  1896. 

Pean.  Bull.  Acad,  de  Med.,  Tome  iii,  p.  31, 
1897. 

Ablation  of  the  cervical  sympathetic 
has  been  abandoned. 

Partial  Resection  {^Removal  of  the  Su- 
perior Ganglion^  and  Partial  and  Ex- 
tensive Resictioti  {Removal  of  the  Supe- 
rior and  Middle  Ganglia  with  the  Intcr- 
veni)ig  Strand)  . — These  procedures  have 
gained  an  established  position  among 
exophthalmic  goitre  operations.  Balas- 
cesu  reports  twenty -seven  cases  which 
were  treated  by  partial  resection,  and 
were  observed  for  periods  varying  from 
one  to  four  years.  In  all  of  these  cases 
there  was  a  rapid  and  pronounced  improve- 
ment. The  exophthalmos  disappeared  with 
the  first  few  days,  the  thyroid  diminished 
in  the  first  eight  days,  but  the  tachycardia 
persisted,  the  pulse  ranging  from  no  to 
120.  The  palpitation  did  not  return  and 
the  facial  expression  was  changed  for  the 
better.  After  a  time  the  tachycardia 
showed  a  tendency  to  decrease,  but  never 
was  as  pronouncedly  influenced  as  were 
the  other  Basedow  symptoms.  In  this 
series  of  twenty-seven  cases  there  were 
nine  cures,  eleven  improvements,  two 
uncured  cases  and  five  deaths,  none  of 
which  could  be  attributed  to  the  opera- 
tion. 

The  mortality  of  these  procedures  is 
small,  probably  less  than  5  per  cent.  Sud- 
den death,  however,  has  occurred  after 
partial  resection.  One  such  case,  which 
was  operated   bilaterally  by  Bernays  and 

Simpson,  of  St.   Louis,  died  on  the 

day. 

That  partial  resection  is  not  always 
curative  is  shown  by  a  case  recorded  by 


SURGERr  OF  THE   TIIVROID. 


157 


Chauffaud  and  Quenu,  who  removed  the 
superior  ganglia  without  influencing  the 
exophthalmos  and  goitre. 

It  seems  reasonable  to  concede  (i)  that 
partial  resection  is  the  operation  of  choice 
in  those  cases  of  exophthalmic  in  which 
the  ocular  and  thyroid  are  more  prominent 
than  the  cardiac  symptoms  ;  (2)  that  the 
bilateral  resection  should  be  made,  but 
not  at  the  same  sitting,  an  interval  of  two 
or  three  weeks  being  advisable  ;  (3)  that 
the  mortality  is  low.      (Ball.) 

BIBLIOGRAPHY. 

Balascesu.  Archiv.  fur  Klinische  Chirurgie, 
1902. 

BernayB  and  Simpson.  Personal  communica- 
tion. 

Chauffaud  et  Q^'enu.  Prcsse  Med'cale,  July 
3.  1897. 

Total  Bilateral  Resection. — This  is  the 
procedure  of  choice  among  the  sympa- 
thetic opera' ions.  Of  nineteen  cases  which 
are  reported  by  Balascesu  as  occurring  in 
the  practice  of  Jonnesco,  Soulie,  Fuure, 
Penguecz,  in  fourteen  after  the  second 
day  after  operation  the  Basedow  symp- 
toms disappeared  one  after  another.  This 
improvement  continued  daily  until  cure 
was  complete.  This  report  is  verified  by 
the  experience  of  Halslead  and  Wither- 
spoon.  Halstead,  writing  four  weeks  after 
total  bilateral  resection,  says:  "The  pa- 
tient'sexophthalmoshasgreatly  improved  ; 
the  pulse  is  better,  the  tremor  and  general 
nervous  condition  are  improved." 

Witherspoon,  in  1899,  was  consulted 
by  a  woman,  aged  fifty  nine  years,  who 
showed  moderate  exophthalmos,  marked 
enlargement  of  the  right  thyroid  lobe,  and 
a  pulse  rate  varying  from  130  to  150.  She 
heard  strange  noises  and  had  ideas  of  per- 
secution ;  the  skin  was  moist  and  the  urine 
showed  casts  and  albumin.  The  diagnosis 
was  chronic  interstitial  nephritis  asso- 
ciated with  Graves'  disease.  Believing 
that  in  her  general  condition  thyroidec- 
tomy was  contraindicated,  Witherspoon 
advised  sympathectomy.  On  Septem- 
ber 10  the  operation  was  made  on  the 
right  lobe.  Eleven  days  later  the  left  side 
was  operated.  After  the  second  operation 
the  pulse  showed  improvement  in  quality 
and  rate,  the  exophthalmos  and  enlarge- 
ment of  the  thyroid  almost  completely 
disappeared  and  her  mental  condition  im- 
proved. In  December  she  went  on  a  visit 
to  the  country.  In  the  following  February, 


while  riding,  she  became  chilled  and  died 
two  hours  afterward. 

BIBLIOGRAPHY. 

Depape.  Societe  Royale  des  Sciences  Reidi- 
coles  et  Naturalles  de  Brussels,  1898. 

Balascesu.  Arrhiv.  fur  Klinische  Chirurgie, 
1902. 

Halstead.  Personal  communication,  April  14, 
1902. 

Witherspoon.  Personal  communication,  April 
15.  1902. 

Classification  of  operations  on  the 
cervical  portion  of  the  sympathetic 
nerve,  where  procedures  which  have  been 
tried  in  the  treatment  of  exophthalmic 
goitre,  are  as  follows: 

1.  Simple  division  of  the  cervical  sym- 
pathetic (first  performed  by  Jaboulay). 

2.  Ablation  of  the  cervical  sympathetic 
consisting  in  the  torsion  and  ablation  of 
the  nerve  by  means  of  artery  forceps  passed 
through  a  small  incision  (Jaboulay's  pro- 
cedure). 

3.  Simple  t>tretching  of  the  cervical 
sympathetic  (first  practiced  by  Jaboulay). 

4.  Partial  resection  of  the  cervical  sym- 
pathetic (first  performed  by  Alexander, 
of  Edinburgh,  in  1889,  for  the  cure  of 
epilepsy  and  limited  by  him  to  the  removal 
of  the  superior  ganglion). 

5.  Partial  and  extensive  resection  (ex- 
cision of  the  upper  and  middle  ganglia 
with  the  intervening  strand). 

6.  Total  resection  of  the  cervical  sym- 
pathetic (removal  of  all  three  ganglia  and 
the  nerve  strand).  This  was  first  per- 
formed by  Jennesco. 

7.  Thyroidectomy  with  partial  and  ex- 
tensive resection  of  the  cervical  sypathet'c 
was  suggested  by  the  writer  in  1901,  and 
was  practiced  by  Dr.  J.  W.  Smith,  of  St. 
Louis  (J.  M.  Ball). 

Conclusions  of  my  paper  read  at  New 
Orleans  : 

1 .  Excision  of  the  superior  cervical  gan- 
glion of  the  sympathetic  nerve  is  worthy 
of  a  trial  in  those  cases  of  simple  atrophy 
of  the  optic  nerve  which  resist  measures 
less  heroic. 

2.  It  is  yet  impossible  to  say  whether 
the  bilateral  operation  is  advisable  in  uni- 
lateral optic  nerve  atrophy. 

3.  The  value  of  sympathectomy  in  con- 
genital hydrophthalmos  has  not  been 
demonstrated. 

4.  In  exophthalmic  goitre  complete  ex- 
cision of  the  cervical  sympathetic  is  fol- 
lowed by  a  larger  percentage  of  cures  than 


158 


Si/RGBRr  OF  THE   THYROID. 


is  any  other  procedure.  Thus  far  no 
deaths  have  been  recorded.  The  number 
of  operations,  however,  is  small  and  final 
conclusions  can  be  announced  only  after  a 
large  number  of  cases  shall  have  been 
treated  by  this  method  (J.  M.  Ball). 

SUKGKRV  OK   SYMPATHETIC    NEKVE   FOR 
EXOPHTHALMIC    GOITRE. 

Historical. — Jaboulay,  1S91  ;  Admed 
Hussein,  1896;  Pean,  1897;  Marchant  and 
Abadie,  1897,  each  made  an  excision  of 
the  sympathetic  nerve  for  exophthalmic 
goitre. 

Valencon,  1S97,  described  surgical 
treatment  for  exophthalmic  goitre,  and 
Rosa,  1897,  said  that  surgery  of  the  sympa- 
thetic nerve  was  the  treatment  tor  ex- 
ophthalmic goitre. 

Viguard,  1S97,  wrote  on  the  treatment 
of  exophthalmic  goitre  by  excision  of 
sympathetic  nerve. 

Soulie,  1897,  contributed  his  study  of 
exophthalmic  goitre  and  its  treatment 
by  excision  of  the  sympathetic  nerve. 

Jonnesco,  1897,  made  a  total  excision 
of  the  sympathetic  nerve  for  exophthalmic 
goitre. 

Chauffard  and  Quenu,  1897,  made  a 
bilateral  resection  of  the  sympathetic  nerve 
for  exophthalmic  goitre. 

Faure,  1896,  treated  exophthalmic 
goitre  by  total  resection  of  the  sympa- 
thetic nerve. 

Poncet,  1897,  and  Bernaud,  1897,  re- 
ported two  cases  of  exophthalmic  goitre 
treated  successfully  by  resection  of  the 
sympathetic  nerve. 

Tremoin,  1898,  made  a  resection  of 
the  sympathetic  nerve  for  exophthalmic 
goitre. 

Bled,  1898,  operated  on  the  sympathetic 
nerve  for  exophthalmic  goitre. 

Schwartz,  1898,  made  a  resection  of 
sympathetic  nerve  for  exophthalmic  goitre. 

Durand,  1898,  made  a  partial  resection 
of  sympathetic  nerve  for  exophthalmic 
goitre. 

Despage,  1898,  treated  exophthalmic 
goitre  by  resection  of  sympathetic  nerve. 

Delageniere,  1898,  made  resection  of 
sympathetic  nerve  for  exophthalmic  goitre. 

Peugniez,  1898,  made  a  bilateral  re- 
section of  sympathetic  nerve  for  exoph- 
thalmic goitre. 

Comemale  and  (yaudier,  1898,  operated 
on  sympathetic  nerve  for  exophthalmic 
goitre. 


Cerkez  and  Juvara,  1898,  made  a  double 
extirpation  for  exophthalmic  goitre. 

Jeunet,  1898,  contributed  his  study  on 
resection  of  sympathetic  nerve  for  exoph- 
thalmic goitre. 

Notys,  1898,  also  contributed  to  the 
treatment  of  exophthalmic  goitre  by  a 
bilateral  resection  of  sympathetic  nerve. 

Boissou,  1898,  made  a  critical  study  of 
the  surgical  treatment,  for  ex>[)hthahnic 
goitre. 

Gaudier.  1899,  made  a  double  sympa- 
thectomy for  exophth;ilinic  goitre. 

Dastre,  1899,  contributed  his  study  on 
surgical  treatment  of  the  sympallietic 
nerve  for  exophthalmic  goitre. 

Abadie,  1899.  made  a  resection  of  the 
sympathetic  nerve  for  exophthalmic  goitre. 

Lorentz,  1899,  treated  exophthaltnic 
goitre  by  operation  on  the  sympathetic 
nerve. 

Boinet,  1899.  m.'ide  a  total  resection  of 
sympathetic  nerve  for  exophtlialmic  goitre. 

Mariani,  1S99,  operated  bilaterally  on 
the  sympathetic  nerve  for  exophthalmic 
goitre. 

Coomes,  1900,  removed  the  sympathetic 
ganglia  for  the  relief  of  exophthalmic 
goitre  with  the  report  of  the  case. 

Curtis,  1900,  made  a  resection  of  the 
sympathetic  for  exophthalmic  goitre. 

Witherspoon,  1899,  removed  both 
sympathetic  nerves  (two  sittings,  resulting 
in  great  relief) . 

Curtis  {Annals  of  Surgery,  August, 
1903,  p.  161- 201 )  considers  thyroidectomy 
and  sympathectomy  for  exophthalmic 
goitre,  and  reports  eleven  females,  partial 
thyroidectomies,  eight  recoveries,  three 
deaths.  Six  females  subjected  to  sympa- 
thectomy, four  recoveries,  two  deaths. 
One  male  on  whom  he  mude  a  sympa- 
thectomy died.  Total  thyroidectomies 
eleven,  three  deaths  due  to  thyroidiiie. 
Total  sympathectomies  seven,  three 
deaths.  Here  we  have  less  than  25  per 
cent,  mortality  in  his  thyroidectomies, 
and  more  than  40  per  cent,  mortality  in 
his  sympathectomies. 

Deaver  {Annals  of  Surgery^  August, 
1903,  p.  202-211)  writes  on  the  surgical 
treatment  of  exophthalmic  goitre,  and  re- 
ported a  bilateral  sympathectomy  on  a 
female,  with  recovery.  Exophthalmos 
cured,  but  the  goitre  remained  without 
discomfort.  He  prefers  sympathectomy 
to  thyroidectomy  or  other  operations  for 
exophthalmic    goitre.     He    also     advises 


SURGERT  OF  THE    THYROID. 


159 


sympathectomy  in    the  treatment  of  epi- 
lepsy. 

BIBLIOGRAPHY. 

Jaboulay.     Ljon  med.,  1891,  Ixxxi,  389. 
Lancereaux.      La    Seniaine     Medicale,    Pari?, 
January,  1894. 

Gayet,  G.     Lyon  med.,  1896,  Ixxxii,  419  428. 

Alimed  Hussein.     Lyon,  i8t,6. 

Tricomini.     II  Policlinico,  Roma,  1896. 

Province  med.,  Lyon,  1897,  xi,  82. 

Surrell.     These  de  Paris,  1897. 

Pean.   Bull.  acad.  de  med.,  Paris,  1897,  xxxviii, 

132-1.-^7- 

De  Cvon.     Acad,  des  sciences,  1897.  Juin. 

Marchant  and  A.badie.  Pre?se  med.,  Paris, 
1897,  i')  I- 

Valencon,  P.  Gaz.  d.  hop.,  Paris,  1897,  Ixx, 
603-700. 

Rosa,   U.    Suppl.  al    Policlin.,  Roma,   1897  8, 

i^.  30  33- 

Viguard.  Bull,  med.,  Paris,  1897,  xi,  167- 
170.  , 

Soulie.     Arch.  prov.  de  chir.,  Paris,  1897,  vi, 

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1900)    Wiesbaden,  1901. 

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May,  1900. 

EXOPHTHALMIC  GOITRE. 

Historical. — Parry,  1825.  reported  a 
case  of  enlargement  of  the  thyroid  gland 
in  connection  with  enlargement  or  palpi- 
tation of  the  heart. 

Debar,  1830,  contributed  his  observa- 
tions on  exophthalmic  goitre. 

Von  Basedow,  1840,  described  exoph- 
thalmic goitre  as  an  enlargement  of  the 
thyroid  gland  with  protrusion  of  the  eye- 
balls. 

MacDonnell,  1845,  made  observations 
on  a  peculiar  form  of  disease  of  the  heart 
attended  with  enlargement  of  the  thyroid 
gland  and  eyeballs. 

Begbie,  1848,  described  a  case  of  anemia 
and  its  consequences — enlargement  of  the 
thyroid  gland  and  eyeballs — and  asks  the 
question  :  "  Anemia  and  goitre,  are  they 
related?" 

Banks,  1855,  reported  his  observations 
on  the  increased  action  of  the  heart  and 
arteries  of  the  neck,  with  enlargement  of 
the  thyroid  gland  and  prominence  of  the 
eyeballs,  dropsy,  etc. 

Stokes,  1855,  recognized  the  increased 
action  of  the  heart  and  of  the  arteries  of 
the  neck,  followed  by  enlargement  of  the 
thyroid  gland  and  eyeballs. 

Charcot,  1856,  described  the  character- 
istics of  exophthalmic  goitre  as  palpitation 


i6o 


SURGERY  OF  THE   TIIYROID. 


of  the  heart,  increased  action  of  the  ar- 
teries, swelling  of  the  thyroid  gland,  and 
abnormal  protrusion  of  the  eyeballs. 

Markham,  1857,  reported  an  affection 
of  the  heart  with  enlargement  of  the  thy- 
roid and  thymus  glands  and  prominence 
of  the  eyeballs. 

Harimann,  1859,  mentioned  exophthal- 
mic goitre  with  dilatation  of  the  heart. 

Williams,  i860,  contributed  his  obser- 
vations on  exophthalmic  goitre. 

Hamburger,  1862,  reports  exophthalmic 
goitre  as  an  epidemic. 

Begbie.  1863,  reported  a  case  of  vascu- 
lar bronchocele  and  exophthalmos. 

Moore,  1863,  described  palpitation,  vis- 
ible pulsation  in  the  carotids  and  thyroid 
gland,  with  exophthalmia. 

Laycock,  1863,  wrote  on  the  causes  and 
nature  of  the  vascular  kind  of  bronchocele 
and  of  the  pulsations  and  palpitations 
termed  anemic. 

Begbie,  1863,  described  bronchocele  and 
exophthalmos. 

Turgis,  1863,  contributed  his  researches 
and  observations,  with  history  of  exoph- 
thalmic goitre. 

Collard,  1863.  reported  the  case  of  a 
young  woman  where  exophthalmic  goitre 
was  attended  by  congestion  of  the  grand 
sympathetic  nerve. 

Tatum,  1864,  recorded  a  case  of  exoph- 
thalmic goitre ;  sloughing  of  the  cornea 
from  exposure. 

Reiih,  1S65,  reported  a  case  of  exoph- 
thalmos enlargement  of  the  thyroid  gland  ; 
autopsy,  affection  of  the  cervical  sympa- 
thetic. 

Chalubinski  Choroba,  1866,  reported  a 
case  of  exophthalmic  goitre  with  chronic 
bronchitis. 

Rose,  1S67,  described  carcinoma  of  the 
thyroid  gland,  with  palpitation  of  the 
heart  and  exophthalmos. 

Fournier  and  Ollivier,  1868,  reported 
exophthalmic  goitre  resulting  in  gangrene 
of  the  grand  sympathetic  nerve. 

Chvostek,  1869,  described  exophthalmic 
goitre  and  Basedow's  disease  as  one  and 
the  same. 

Andrews,  1870,  mentioned  exophthal- 
mic goitre  with  insanity. 

Patchett,  1872,  exophthalmic  goitre, 
with  unusual  severity  of  symptoms  ;  ulcer 
of  cornea ;  cured. 

Vance,  1873,  reported  ophthalmoscopic 
appearances  in  cases  of  exophthalmic 
goitre. 


Daviller,  1873,  considered  the  physiol- 
ogy of  exophthalmic  goitre. 

Smith,  1874,  treated  exophthalmic  goitre 
with  belladonna. 

Goodhart,  1874,  reported  exophthalmic 
goitre  with  enlargement  of  thymus. 

Bartholow,  1875,  gave  some  practical 
observations  on  exophthalmic  goitre  and 
its  treatment. 

Bulkley,  1875,  reported  two  cases  of 
exophthalmic  goitre  associated  with 
chronic  urticaria. 

Boddaert,  1S75,  contributed  his  study  of 
the  physiology  of  exophthalmic  goitre. 

Walzberg,  reported  a  case  of  exophthal- 
mic goitre  with  abnormal  protru8ion_^of 
the  eyeballs. 

Gagnon,  1876,  reported  an  exophthal- 
mic goitre. 

O'Neill,  1878,  reported  exophthalmic 
goitre  and  diabetes  occurring  in  the  same 
person. 

Smith,  1878,  reported  exophthalmic 
goitre  lesions  of  the  cervical  ganglia. 

Eales,  1S78,  described  exophthalmic 
goitre  with  unilateral  exophthalmos. 

Earle,  1878,  considered  the  frequency 
of  exophthalmic  goitrejin  Illinois,  with  a 
brief  consideration  of  its  recent  pathology 
and  treatment. 

Morgan,  1S79,  reported  on  dilatation  of 
the  cavities  of  the  heart  with  probably 
some  hypertrophy,  complicated  with  ex- 
ophthalmic goitre, successfully  treated  with 
digitalis. 

Cornwell,  1880,  recorded  a  case  of  ex- 
ophthalmic goitre  terminating  in  total  loss 
of  sight  from  neuro-paralytic  inflammation 
of  the  cornea. 

Blackwood,  1880,  had  a  case  of  exoph- 
thalmic goitre  which  he  treated  by  elec- 
tricity. 

Stewart,  1881,  reported  three  cases  of 
exophthalmic  goitre  treated  by  ergot. 

Desnos,  1881,  treated  an  exophthalmic 
goitre  by  injections  of  duboisin. 

Merklen,  1882,  described  a  case  of  ex- 
ophthalmic goitre  resulting  from  a  fever 
and  epilepsy  ;   recovery. 

Fauquez,  1882,  made  observations  on 
exophthalmic  goitre  originating  with  men- 
struation ;   recovery. 

Hunt,  1883,  reported  on  exophthalmic 
goitre  treated  with  duboisinja. 

Major,  1883,  reports  an  exophthalmic 
goitre,  hygroma  and  acute  inflammation 
of  thyroid  gland,  with  illustrative  cases. 

Fitzgerald,  1883,  contributed  an  article 


SURGERl'  OF  THE    THTROID. 


i6i 


on  "The  Theory  of  a  Central  Lesion  in 
Exophthalmic  Goitre." 

Savage,  18S3,  and  Greidenberg,  1883, 
reported  on  mental  disturbance  in  Base- 
dow's disease. 

Maher,  1885,  reported  on  exophthalmic 
goitre  with  unilateral  exophthalmos. 

Santangelo,  in  Seta,  1885,  made  an 
experimental  research  in  exophthalmic 
goitre. 

Marie,  i8Sy,  made  observations  on  ex- 
ophthalmic goitre. 

Syers,  1886,  had  a  case  of  exophthalmic 
goitre  terminating  fatally. 

DeRause,  1886,  reported  on  treatment 
of  exophthalmic  goitre. 

Aiken,  1887,  reported  a  case  of  exoph- 
thalmic goitre  following  ether  anesthesia. 

Lloyd,  1887,  reported  a  case  of  rapidly 
fatal  exophthalmic  goitre. 

Dubreuilh,  1887,  exophthalmic  goitre 
with  tuberculosis. 

Vierodt,  1887,  described  the  combina- 
tion of  exophthalmic  goitre  with  laryn- 
gitis. 

Moore,  1887,  reported  exophthalmic 
goitre  with  loss  of  an  eye  by  exposure. 

Brower,  1888,  reported  on  exophthal- 
mic goitre  and  its  treatment  by  tincture 
of  strophanthus. 

Burton,  1888,  reported  on  cutaneous 
affections  in  exophthalmic  goitre. 

Kurella,  1888,  reported  bronzed  skin 
accompanying  exophthalmic  goitre. 

Cohen,  1889,  had  a  case  where  ex- 
ophthalmic goitre  was  associated  with 
phthisis. 

White,  1889,  reported  on  the  pathology 
of  the  central  nervous  system  in  exoph- 
thalmic goitre. 

Semon,  1889,  had  a  case  of  unilateral 
incomplete  exophthalmic  goitre  after  re- 
moval of  nasal  polypi. 

Deunitieres,  1889,  reported  a  fatal  case 
of  exophthalmic  goitre. 

Thyssen,  1889,  mentioned  hereditary 
possibilities  in  exophthalmic  goitre. 

Hutchinson,  1889,  reported  on  recovery 
from  exophthalmic  goitre,  with  note  on 
the  non-liability  to  recurrences  of  the  dis- 
ease and  on  the  great  importance  of  change 
of  climate  in  its  treatment. 

Finlayson,  1890,  reported  on  paralysis 
of  the  third  nerve  as  a  complication  of  ex- 
ophthalmic goitre. 

Rosenberg,  1890,  reported  a  case  of  ex- 
ophthalmic goitre,  apparently  hereditary. 

Bramwell,  1890,  reported  on  the  symp- 


toms of  myxedema  and  exophthalmic  goitre 
contrasted. 

Weil  and  Diamantberger,  1891,  reported 
a  case  of  exophthalmic  goitre  associated 
with  rheumatism.  Another  case  is  re- 
ported of  exophthalmic  goitre  in  a  girl 
causing  death  by  asphyxia. 

Lawford,  1890,  reported  a  case  of  re- 
covery from  exophthalmic  goitre. 

Montgomerie,  1891,  reported  a  case  of 
exophthalmic  goitre  ending  fatally  from 
sudden  pressure  on  the  trachea. 

Lashtshenko,  1891,  reported  on  exoph- 
thalmic goitre  and  alcoholic  automatism. 

Spencer,  1891,  reported  a  case  of  ex- 
ophthalmic goitre  causing  death  by  as- 
phyxia. 

Nine  cases  of  exophthalmic  goitre  ;  oph- 
thalmoplegia ;  remarks  on  the  lid  symp- 
toms (St. Bartholomew  Hospital  Reports) . 

Sollier,  1891,  recorded  a  case  of  exoph- 
thalmic goitre  with  myxedema. 

Bradshaw,  1891,  recorded  a  case  of  ex- 
ophthalmic goitre  complicated  by  hemi- 
plegia and  unilateral  chorea. 

Cardew,  1891,  reported  on  the  value  of 
diminished  resistance  of  the  human  body 
as  a  symptom  in  exophthalmic  goitre. 

Hay,  1891,  described  a  case  of  exoph- 
thalmic goitre  with  mental  disease  ;  report 
of  three  cases  with  rare  complications. 

Rosenblatt,  1892,  reported  on  trembling 
of  the  limbs  as  a  first  symptom  of  exoph- 
thalmic goitre. 

Maude,  1892,  reported  on  the  use  of 
Leiter's  tubes  to  the  precordium  in  exoph- 
thalmic goitre. 

Jeafferson,  1893,  mentioned  thyroid 
secretion  as  a  factor  in  exophthalmic 
goitre. 

Mader,  1893,  reported  a  case  of  exoph- 
thalmic goitre  with  compression  of  the 
trachea,  terminating  in  lobular  pneu- 
monia. 

Broomall,  1893,  reported  on  exoph- 
thalmic goitre;  death  on  the  twentieth 
day  after  a  Porro  operation  for  uterine 
fibromata. 

Yema,  1893,  considered  "muscular 
twitchings"  in  exophthalmic  goitre. 

0'Donovan,i894,  had  a  case  of  exoph- 
thalmic goitre  treated  during  two  years 
with  tincture  of  strophanthus. 

Auld,  1894,  reported  on  the  effect  of 
thyroid  extract  in  exophthalmic  goitre 
and  in  psoriasis. 

Wood,  1894,  reported  a  case  of  exoph- 
thalmic goitre  with  spontaneous  cure  oc- 


l62 


SURGBRr  OF  THE   THYROID. 


curring  apparently  from  the  use  of  extract 
of  spleen. 

Dourdoufi,  1894,  contributed  a  study  on 
the  relation  of  myxedema  to  exophthalmic 
goitre. 

West,  1895,  reported  two  ca?es  of  ex- 
ophthalmic goitre  in  sisters  with  morbus 
cordis,  and  a  history  of  rheumatic  fever  in 
both. 

Moore,  1895,  reported  on  exophthalmic 
goitre  and  its  treatment  with  sodium 
phosphate. 

Watson  Williams,  1S95,  had  a  ca^e  of 
exophthalmic  goitre  with  unilateral  symp- 
toms treated  by  thyroid  feeding,  etc. 

Power,  1895,  reported  on  exophthalmic 
goitre  treated  with  thyroid  extract. 

Bacon,  1895,  reported  on  the  treatment 
of  exophthalmic  goitre  with  nuclein 
solution. 

Bogroff,  1895,  reported  nine  cases  of 
exophthalmic  goitre  with  injections  of 
thyroid  gland. 

Cunningham,  1895,  reported  on  the  ad- 
ministration of  thymus  in  exophthalmic 
goitre. 

Hektoen,  1895,  considered  hyperplastic 
persistent  thymus  in  exophthalmic  goitre. 

Bouchaud,  1895,  wrote  on  the  heredi- 
tary possibillities  in  exophthalmic  goitre. 

Fridenherg.  189:;,  reported  a  ca<=e  of 
exophtiuilmic  guilre  willi  monocular 
symptoms  and  unilateral  th)roid  hyper- 
trophy. 

Baldwin,  1895,  reported  some  cases  of 
exophthalmic  goitre  succeeded  by  thyroid 
atrophy. 

Hannemann,  1895,  had  a  case  of  exoph- 
thalmic goitre  resulting  in  glycosuria  and 
diabetes. 

Edes,  1896,  reported  on  the  treatment 
of  exophthalmic  goitre  with  animal  ex- 
tracts, and  especially  extract  of  thymus. 

Smith,  1896,  reported  a  case  of  exoph- 
thalmic goitre  with  marked  tremors 
treated  with  thyroid  extract  and  iodine  in- 
jection ;  slight  improvement  in  the  end, 
but  symptoms  appeared  worse  under  the 
thyroid  treatment. 

Goldschmidt,  1896,  mentioned  a  glyco- 
suria with  exophthalmic  goitre. 

Kinnicutt,  1896,  reported  on  the  theory 
of  the  thyroid  origin  of  exophthalmic 
goitre,  with  its  bearing  on  the  surgical 
treatment  of  the  disease. 

^Mackenzie  and  Edmonds,  1S96,  re- 
ported two  cases  of  exophthalmic  goitre 
with  persistent  thymus. 


Georgiyevski,  1900,  contributed  a  short 
sketch  on  the  epidemic  of  fulminating 
goitre  in  Vilmanstand  in  the  autumn  of 
1896. 

Smith,  1896,  reported  on  exophthalmic 
goitre  with  glycosuria  and  general  alo- 
pecia. 

Bettmann,  1896,  reported  a  case  of  ex- 
ophthalmic goitre  with  diabetes. 

Cohen,  1897,  reported  on  the  treatment 
of  exophthalmic  goitre  and  other  vaso- 
motor ataxias  with  preparations  of  the 
thymus  gland  and  of  the  adrenals. 

Crary,  1897,  described  the  use  of  the 
extract  of  suprarenal  capsule  in  exoph- 
thalmic goitre. 

James,  1897,  reported  a  case  of  exoph- 
thalmic goitre  treated  with  extract  of 
thymus  gland. 

Kerley,  1897,  reported  an  apparent 
cure  of  exophthalmic  goitre  by  the  use  of 
thyroid  extract. 

Curtin,  1897,  reported  on  heredity  as  a 
primary  factor  in  exophthalmic  goitre, 
with  remarks  on  other  etiological  in- 
fluences. 

Low,  1897,  considered  edema  in  exoph- 
thalmic goitre. 

Mackenzie,  1897,  had  a  case  of  edema 
in  exophthalmic  goitre. 

Troit'^ki,  1897,  had  a  case  of  exoph- 
thiilinic  g  .itre  wtili  erysipelas,  terminating 
in  complete  recovery. 

Murray,  1897.  considered  acromegaly 
with  goiire  and  exophthalmic  goitre. 

Bradley  and  Eyre,  1897,  reported  some 
cases  of  exophthalmic  goitre  associated 
with  increased  intraocular  tension. 

Belloli,  1898,  treated  exophthalmic 
goitre  with  suffocation. 

Gillespie,  1898,  contributed  a  note  on 
the  action  of  bromide  and  iodine  of 
strontium  on  exophthalmic  goitre  in  chil- 
dren. 

Brower,  1898;  Holmes,  1898,  each  re- 
port four  cases  of  family  type  of  exoph- 
thalmic goitre. 

Fraiken,  1898,  mentioned  acromegaly 
coexistent  with  exophthalmic  goitre. 

GrifHlh,  1898,  reported  on  a  case  of  acute 
exophthalmic  goitre  with  ulcerative  kera- 
tosis. 

ISIiller,  1898,  had  a  case  of  exophthalmic 
goitre  with  unilateral  eye  symptoms. 

Putnam,  18(5,8,  reported  on  the  clinical 
aspects  of  the  internal  secretions;  nature 
of  the  thyroidal  cachexis  infantilism 
acromegaly. 


SURGERY  OF  THE   TIU'ROID. 


163 


Noble,  1S98,  reported  abdominal  section 
on  a  patient  suffering  from  exophthalmic 
goitre. 

Kalblleisch,  1S98,  reported  on  exoph- 
thalmic goitre,  chorea  confinement  and 
heart  failure. 

Mollard  and  Bernoud,  1S9S,  reported 
respiratory  ditliculties  in  exophthalmic 
goitre  resulting  in  tuberculosis. 

Szontagh,  1899,  reported  on  exoph- 
thalmic goitre  and  its  successful  cure  at 
New  Tatra  in  eighty-two  cases. 

Allan,  1S99,  gave  his  suggestion  as  to 
the  treatment  of  exophthalmic  goitre  by 
the  administration  of  bile  through  the 
mouth,  hypodermatically  and  intrathy- 
roidal,  with  cases. 

Minor,  1899,  reported  two  cases  of  ex- 
ophthalmic goitre  treated  successfully  as 
intestinal  autointoxication. 

Pitres,  1899,  reported  on  the  treatment 
of  exophthalmic  goitre  with  injection  of 
iodoform. 

Iho,  1899,  reported  on  exophthalmic 
goitre  in  gynecology. 

Beard,  1899,  had  a  case  of  exophthal- 
mic goitre  attended  by  rapid  increase  in 
myopia  occurring  in  an  elderly  subject. 

Shepherd,  1899.  gave  some  remarks  on 
the  symptoms  and  operative  treatment  of 
bronchocele,  especially  in  relation  to  ex- 
ophthalmic goitre. 

Hinshelwood,  1900,  reported  a  case  of 
exophthalmic  goitre  which  improved  un- 
der treatment  with  antipyrine. 

Jacobi,  1900,  treated  exophthalmic 
goitre  by  intestinal  antisepsis. 

Armstrong,  1900,  reported  a  fatal  case 
of  exophthalmic  goitre  in  a  girl  eleven 
years  old. 

Harland,  1900,  contributed  notes  on  two 
cases  of  exophthalmic  goitre  appearing 
suddenly  in  men  who  have  been  in  action. 

vSutherland,  1900,  described  a  case  of 
cyclic  albuminuria  and  exophthalmic  goi- 
tre. 

Nicol,  1900,  reported  on  cutaneous 
hemorrhage  and  pigmentation  in  a  case  of 
exophthalmic  goitre. 

Ryan,  1900,  reported  a  case  of  unilateral 
exophthalmic  goitre. 

Abt,  1900,  had  a  case  of  congenital 
goitre  and  diaphragmatic  hernia. 

Pasteur,  1900,  reported  a  case  of  myxe- 
dema supervening  on  exophthalmic  goitre. 

Ilerringh;  m.  1900  meiiti')iied  a  case  of 
exophthahnic  goitre  with  extreme  emacia- 
tion. 


Stewart,  1900,  reported  a  case  of  acute 
Graves'  disease  without  exophthalmic 
goitre. 

Warner,  1900,  reported  ophthalmoplegia 
externa  complicating  a  case  of  Graves' 
disease. 

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eases, March,  1903,  p,  142, 


178 


SURGERT  OF  THE   THTROID. 


CRETINISM    (180I-I904). 

Characterized  by  physical,  physiologic 
and  mental  non-development  from  infancy, 
the  subject  seldom  reaching  five  feet  in 
height,  due  to  congenital  absence  of  thy- 
roid gland. 

Myxedema,  a  disease  of  adult  life,  is 
due  to  the  absence  of  thyroid  tissue, 
whether  removed  by  disease  or  otherwise. 
It  may  result  from  atrophy  of  the  gland. 

The  neck  is  thick,  arms  and  legs  short, 
abdomen  large,  tongue  protruding,  with 
imbecility  or  idiocy. 

Coitus  during  intoxication  is  supposed 
to  be  a  cause  of  myxedema,  not  well 
founded. 

Cretinism  or  myxedema  may  be  asso- 
ciated with  enlargement  of  the  tkyroid 
body,  but  that  body  has  been  converted 
into  connective  tissue  as  the  result  of  dis- 
ease, with  the  loss  of  physiologic  thyroi- 
dine. 

Treatment. — There  is  but  one  known 
remedy,  that  is  in  the  administration  of 
the  thyroid  or  thymus  secretion  taken  from 
animals.  This  must  be  given  as  long  as 
the  patient  lives,  and  stands  as  one  of  the 
greatest  achievements  in  the  practice  of 
physic.  Their  administration  never  cures  ; 
is  only  palliative,  and  sometimes  fails  to 
do  that. 

Historical. — Fodere,  1800,  delivered  a 
discourse  on  cretinism  and  the  influence 
of  altitude  on  it,  wkile  DuMirari,  July, 
1831,  presented  his  memoirs  on  cretinism, 
its  causes  (natural,  accidental  and  dis- 
eases), hereditary  influences  and  precau- 
tions. 

De  Baumont,  1851,  reported  his  re- 
searches a»d  relative  causes  of  cretinism, 
and  Giordano,  1866,  considered  its  eti- 
ology. 

Lombard,  1874,  believed  that  cretinism 
was  due  to  atmospheric  influences,  and 
Hermann,  1882,  wrote  on  cretinism  and 
idiocy  and  their  causes. 

BinLIOGRAPHY. 

Fodero.     Rec.  period  soc.  de  med.,  Paris,  1801, 

X,  35-42- 

Du  Mirari  Jeuoj.  Journal  univ.  et  hebd.  de 
medical  et  chirurgie,  prat.,  Paris,  1831,  iii, 
316  329. 

Alciate.  Gior.  d.  society  medical  chirurgie  di 
Torino,  1846,  xxvii,  158  178. 

Barth.     Bull.  soc.  anat.,  Paris,  1850,  xxv,  5. 

Villerme.  Niepee,  2  v,  Paris,  185 1-2,  (review). 

Sztam.     Vratislavia,  1852. 

Gosse.     De  I'etiologie  du  goitre  et  du  cretin- 


ism, Geneva,  1852;  also  ueber  die  aetiologie  des 
kropfes  und  des  kretinisms  schweix.  Ztschr.  f. 
med.  chir.  u.   geburtsch.,  Zurich,  1853,  73-102. 

Fabre.     Paris,  1857. 

Baron.  Contribution  a  I'etiologie  du  goitre  et 
du  cretinisme,  Grenoble,  1867. 

Giordano.  Ezlologin  del  gozzo  e  del  cretin- 
ismo.  Gior  di  med.  mil.  Firenze,  1866,  xiv,  129, 
161,  203,  I  ch. 

Wilson.  Indian  Ann.  Med.  Soc,  Calcutta, 
1873  4.  xvi,  395-404. 

Lombard.  Bull,  society  med.  de  la  Suisse 
Rom.,  Lausanne,  1874,  viii,  6,  55. 

Hermann.  Friedreicb's  bl  f.  gerichtl.  med., 
Nurnburg,  1882,  xrxiii,  37  128,  i  tab. 

Gamba.     Arch,  di  psichiat.,  ete.,  Torino,  1882, 

iii.  437  440- 

Bagliatto.  Asturias  rev.  Asturiana  de  cien 
med.,  Oviedo,  1884  5,  ii,4-io. 

British  Med.  Journal,  London,  1885,  i,  rii,  121. 

Mercandi,  Gioberti.  Gazz.  med.  di  Torino, 
1886,  xxxvii,  633-9. 

Metlesen.  Aetiologie  studier  over  struma, 
Kristiana,  1887. 

Cane.  Canada  Pract.,  Toronto,  1888,  xiii, 
145-149. 

Hanu  Verhandl.  d.  x  international  med.  cong., 
1890,  Berlin,  1891,  ii,  3  abth,,  128-130. 

Murray.  British  Med.  Journal,  London,  1891, 
ii,  796. 

Langhans.  Arch.  f.  path.  anat.  Berlin,  1892, 
cxxviii,  318,  3  pi.,  369. 

Antonini.  Arch,  di  psichiat,  Torino,  1894,  ^^» 
554-S59. 

Gaide.     Bordeaux,  1895,  no  p. 

De  Coulon.  Arch.  f.  path,  anat.,  Berlin,  1897, 
cxlvii,  53  99. 

Laire.     Journal  de  med.  int.,  Paris,   1899,  iii, 

447.  464- 

Graves.  Wichita  Med.  Journal,  March,  1903, 
vol.  2,  pp.  43-49. 

CONCRETIONS   (1837-I9O4). 

Calcareous  and  bony  concretions  varying 
in  size,  shape  and  number;  are  not  infre- 
quently found  within  the  body  of  the  thy- 
roid gland  and  in  its  capsule.  Their  eti- 
ology is  unknown,  except  that  they  may 
form  independently  of  other  pathologic 
changes  in  the  gland  or  its  capsule.  They 
have  been  found  where  the  gland  has  the 
normal  number  of  lobes,  when  the  number 
is  less  than  normal,  and  in  accessory  lobes 
of  any  number,  size  or  position,  and,  like 
hyaline  and  fatty  degeneration,  are  found 
more  frequently  in  advanced  life. 

Historical. — Marjolin,  1837,  recorded  a 
case  of  bony  degeneration  of  the  thyroid 
gland,  and  Fouraytier,  1841,  one  of  a 
similar  character. 

Welford,  1858,  reported  a  case  of  cancer 
of  the  thyroid  gland  with  a  small  bony 
tumor.ij 

Toland  observed  a  bony  depo<iit  in  an 
enlarged  isthmus  and  right  lobe  of  the 
thyroid  gland. 


SURGERT  OF  THE   THYROID. 


179 


Dieu,  1865,  recorded  a  case  of  complete 
calcification  of  the  thyroid  gland. 

Bell,  1894,  mentioned  an  extensive  cal- 
careous deposit  in  an  enlarged  thyroid 
gland,  producing  esophageal  obstruction. 

Jordon,  1894,  reported  a  rare  case  of 
bony  deposit  in  the  thyroid  gland. 

BIBLIOGRAPHY. 

Marjolin.     Bull.    soc.    anat.,    Paris,   1837,   xii, 

39-49- 

Fouraytier.  Bnll.  soc.  anat.,  Paris,  1841, 
xvi,  II. 

BouUaj.     Bull.  soc.  anat.  de  Paris,  1851,  xxvi, 

49- 

Verneuil.  Bull.  soc.  anat.,  Paris,  1851,  xxvi, 
49. 

Welford.  Med.  Times  and  Gazette,  London, 
1858,  xvi,  400. 

Dieu.     Bull.  soc.  anat.,  Paris,  1865,  xi,  173. 

Kebbell.     Lancet,  London,  1877,  ii,  125. 

Jordan.  Orvosi  heti  szemle,  Budapest,  1894, 
XXX,  496. 

Bel).  Montreal  Med.  Journal,  1894-5,  xxiii, 
297. 

CYSTIC    GOITRE     (1682-I9O4). 

Cysts  of  the  thyroid  gland  were  one  of 
its  earlier  pathologic  changes  described. 
They  may  be  of  many  kinds,  varying  in 
size,  shape  and  number,  originating  as  a 
simple  cyst,  and  remaining  so,  or  they 
may  be  complicated  with  other  pathologic 
changes  in  the  thyroid  gland ;  they  may 
be  slow  or  rapid  in  their  development, 
and  any  form  may  become  infected  with 
the  usual  result  of  such  a  condition. 

Historical. — Cesvin,  1680,  reported  the 
cure  of  a  rare  case  of  cystic  goitre,  and 
Dapeyron  de  Cheyssiol,  1768,  made  obser- 
vations on  the  cure  of  cystic  goitre  with 
powdered  egg  shells  ;  dose  internal. 

Rheseu,  1783,  described  bronchocele 
and  dropsy  of  the  ovarium  as  kindred  dis- 
eases, and  Lane,  1787,  reported  a  cure  of 
cystic  goitre  by  the  use  of  burnt  sponge. 

Geddes,  1805,  reported  one  in  which 
the  use  of  codfish  was  resorted  to,  and 
Holbrook,  1817,  made  observations  on  the 
cure  of  bronchocele  by  pressure. 

Denny,  1825,  remarked  on  the  disease 
termed  cystic  goitre,  which  prevailed  in 
Pittsburg  and  its  vicinity,  and  Bramley, 
1833,  gave  an  account  of  the  cystic  goitre, 
in  the  Trans-Himalayan  regions. 

Cooper,  Sir  A.,  1841,  reported  a  case 
of  collection  of  fluid  in  the  substance  of 
the  right  lobe  of  the  thyroid  body. 

Meassey,  1842,  described  cystic  goitre 
with  collection  of  fluid  in  its  substance 
and  its  analysis. 


Velpeau,  1847,  described  his  observa- 
tions on  diagnosis  of  cystic  goitre. 

Maclagnan,  1853,  contributed  the  analy- 
sis of  the  fluid  from  a  cyst  in  the  thyroid 
body. 

Crighton,  1856,  reported  cases  of  con- 
genital cystic  goitre. 

Knode,  i860,  reported  a  case  of  cure  of 
a  degenerated  bronchocele  of  enormous 
size. 

Bullar,  1861,  described  pulsating  cystic 
goitre,  and  Gibb,  1863,  described  a  cystic 
goitre  bulging  the  trachea  inwards  near 
the  bifurcation,  as  seen  with  the  laryngo- 
scope ;  neuralgic  pains  occurred  in  the 
neck  and  elsewhere. 

McWhinnie,  1861,  and  Beraud,  1866, 
contributed  their  observations  on  cystic 
goitre. 

Lombard,  1859,  reported  a  case  of  rup- 
ture of  thyroid,  resulting  in  cystic  goitre, 
in  a  woman. 

Nicholls,  1869,  reported  a  sudden  death 
by  cystic  goitre. 

Masterman,  1870,  made  notes  on  cystic 
goitre  in  Paraguay. 

Bristowe,  1872,  gave  clinical  lectures  on 
a  case  of  substernal  bronchocele. 

Begbie,  1873,  mentioned  the  use  of  al- 
bumen in  cases  of  vascular  cystic  goitre. 

Boechat,  1872,  reported  hypertrophy  of 
the  lower  lobe  of  the  thyroid  with  cystic 
formation. 

Mackenzie,  1873,  described  fibro-cystic 
goitre  in  a  dog. 

Proust,  1875,  reported  a  cystic  goitre  in 
a  consumptive ;  autopsy. 

Roberts,  1876,  described  acute  cystic 
goitre  with  cardiac  hypertrophy  occurring 
during  pregnancy  and  producing  fatal 
dyspnea. 

Marchant,  1876,  described  an  irregular 
development  in  cystic  goitre  with  partial 
ossification. 

Johnson,  1877,  reported  a  cystic  goitre 
causing  paralysis  of  on«  vocal  cord. 

Hovell,  1878,  described  a  fibrocystic 
goitre  constricting  the  esophagus;   death. 

Lutz,  1882,  and  McAlester,  1882,  men- 
tioned congenital  multilocular  cystic  de- 
generation of  the  thyroid  gland. 

Haward,  1881,  reported  a  case  of  cystic 
goitre  with  secondary  growths  in  bones 
and  viscera. 

Deaver,  1885,  described  a  cystic  goitre 
originating  in  an  accessory  thyroid  gland. 

Robinson,  1885,  *'  Endemic  Cystic 
Goitre,"  being  the  thesis  for  the  degree  of 


i8o 


SURGERT  OF  THE   THYROID. 


Doctor  of  Medicine  of  the  University  of 
Durham,  for  which  the  gold  medal  was 
awarded. 

Youman,  1885,  reported  a  case  of  bron- 
chocele  complicated  with  laryngeal  spasm. 

Toison,  1886,  made  observations  on  cys- 
tic goitre  with  analysis. 

Hutchinson,  1888,  described  acute  cys- 
tic goitre  adolescences, an  aunt  and  nephew 
affected  at  corresponding  ages ;  complete 
recovery  of  the  former. 

Pennell,  1889,  reported  a  case  of  cystic 
goitre  with  a  synopsis  of  cystic  goitre 
treated  in  Guy's  Hospital. 

McMordie,  1888,  reported  a  rapid  case 
of  development  of  a  thyroid  cyst,  and 
Symonds,  1893,  described  some  varieties 
of  bronchocele. 

Harris,  1895,  described  a  gelatinous 
cyst,  and  Edmunds,  1895,  mentioned  a 
cystic  accessory  thyroid;  while  Merritt, 
1896,  reported  a  case  of  unilateral  cyst 
with  myxedema. 

Verdun,  1896,  described  a  cystic  goitre 
with  satellites,  and  Jourdanet,  1897,  re- 
ported a  cystic  goitre  with  broncho-pneu- 
monia. 

Heath,  1898,  gave  a  clinical  lecture  on 
cases  of  thyroid  cyst,  and  Lanin,  1898, 
reported  a  cyst  of  an  accessory  thyroid 
gland. 

BIBLIOGRAPHY, 

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1682,  ii,  96. 

Dapeyron  de  Cheyssiol.  Journal  de  med.  chir. 
pharna.,  Paris,  1768,  xxviii,  343,  1770,  xxxii, 
264. 

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1777.  75  91- 

Rhesen.     Tubingae,  1780. 

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Barton.  Trad  de  inglez  por  hyppolito,  Jose 
da  Costa  Pereira,  Lisbon,  1801. 

Carron.  Journal  gen.  de  med. -chir.,  pharm., 
Paris,  1S14,  xlix,  21  25. 

Gibson.  Philadelphia  Journal  Med.  and  Phys. 
Sc,  1820,  i,  44  73. 

Scott.     Edinburgh,   1825. 

Coventry.  New  York  Med.  and  Phys.  Jour- 
nal, 1824,  ili,  162-168. 

Inglis.     Edinburgh,  i8.'5. 

Denny.  Philadelphia  Jour.  Med.  and  Phys. 
Sc,  1825,  x,  47-54. 

Maiden.  London  Med.  Repository,  1826,  xxv, 
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1828,  i,  43. 

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1832,  xxxviii,  319. 

Bramley.  Tr.  Med.  and  Phys.  Society,  Cal- 
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1836,  xlvi,  40  61. 

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SURGERr  OF  THE   THYROID. 


i8l 


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554- 

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537- 

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109. 

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(1883),  1884,  46. 

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kropfe  mit  besonderer  berucksichtung  der  struma 
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xxxi,  328,  422. 


I82 


SURGBRT  OF  THE   THYROID. 


Robinson.  London,  1885  (University  of  Dur- 
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1887  8,  xxxix,  341. 

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X,   197. 

Aerztl.  ber.  d.  k.  k.  krankenh.  zu  Wien  (1886), 
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Hutchinson,     British  Med.  Journal,   London, 

1888,  i,  1374. 

McNordie.     Lancet,  London,  1888,  ii,  166. 
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ECHINOCOCCUS  (185O-I904). 

Cysts  of  this  character  within  the  thy- 
roid gland  are  infrequent.  They  are 
large  or  small,  single  or  multiple,  primary 
or  secondary,  usually  primary,  and  usu- 
ally contain  serum  and  colloid  material. 
Blood  may  occasionally  be  found,  and 
they  may  become  infected  ;  in  either  event 
rupture  may  result  in  the  same  manner  as 
other  forms  of  cysts.  The  parasite  is  sup- 
posed to  pass  through  the  trachea  or 
esophagus  iato  the  gland. 

Historical. — Albers,  1850,  was  among 
the  first  to  report  a  hydatid  cyst. 

Oser,  1884;  Decressac,  1888;  Man- 
teuffel,  1888;  Pean,  1890;  Henle,  1894; 
Vitrac,  1894,  and  Chavier,  1897,  each 
record  a  case  of  hydatid  cyst. 

BIBLIOGRAPHY. 

Albers.  Woch.  f.  d.  ges.  heilk.,  Berlin,  1850, 
xvii,  113  121. 

Oser.      Wien  med.  bl.,  1884,  vii,  1570. 

Reverdin.  Review  de  la  Suisse  R.om.,  Geneve, 
1885,  V,  424. 

Dardel.     Paris,  1888. 

Uecressac.  Bull.  soc.  anat.,  Paris,  1888,  Ixviii, 
684. 

Manteuffel.  St.  Petersburg  med.  woch.,  1888, 
V,  259. 

Pean.  In  his  lecone  de  clin.  chirurgie,  Paris, 
1890,  1 18-130. 

Henle.  Arch.  f.  klin.  chirurgie,  Berlin,  1894- 
5,  xlix,  852  872. 

Vitrac.  Review  de  chirurgie,  Paris,  1897, 
xvii,  421-432  (757-760). 

Chavier.     Gaz.  d.  hop.,  Paris,   1897,  Ixx,  1170. 

BLOOD  CYSTS    (1829-I9O4). 

Blood  cysts  of  the  thyroid  gland  are  in- 
frequent, and  may  be  due  to  injury  or 
disease.  Sudden,  slow  or  rapid  in  growth, 
single  or  multiple,  watery  or  coagulated, 
simple  or  complicated,  movable  or  fixed, 
with  or  without  fever,  dyspnea  or  other 
disturbances.  Infection  may  occur  at  any 
time  in  the  course  of  their  development, 
with  its  usual  consequences. 

Rupture  may  occur  into  the  esophagus, 
trachea,  pleural  cavity,  or  externally 
through  the  cutaneous  structures,  with  fatal 
results  from  loss  of  blood  or  suffocation. 


SURGERY  OF  THE   THTROID. 


183 


Historical. — Meissner.iSag,  was  among 
the  first  to  mention  a  blood  cyst  of  the 
thyroid  gland. 

Albers,  1848,  and  Cruveilhier,  1854, 
each  reported  a  blood  cyst  of  the  thyroid. 

Velpeau,  1857,  contributed  his  obser- 
vations on  the  blood  cyst. 

Edwards,  1864,  described  sero-san- 
guinous  cystic  tumor  of  the  thyroid  gland. 

At  the  Pathological  Society,  London, 
1867,  a  living  specimen  of  blood  cyst  of 
the  thyroid  was  exhibited. 

Rosenbach,  1869,  made  observations  on 
a  blood  cyst,  and  Low,  1878,  reported  a 
goitre  with  hemorrhagic  tendency. 

Derbez,  1880,  contributed  to  the  study 
of  the  blood  cyst  and  its  treatment. 

Berger  and  Onimus  reported  a  blood 
cyst  treated  by  electrolysis. 

Jager-Luroth,  1883,  made  observations 
on  the  blood  cyst  and  its  treatment. 

Osier,  1891,  described  a  large  fibro- 
cystic goitre ;  hemorrhage,  followed  by 
death. 

Simon,  1894,  reported  sudden  death 
caused  by  violent  hemorrhage  of  a  blood 
cyst. 

Mermet,  1896,  reported  his  observations 
on  blood  cysts,  and  Archibald,  1897,  re- 
ported three  cases  of  blood  cysts. 

BIBLIOGRAPHY. 

Chelius.  Bemerkung  uber  die  struma  vascu- 
losa  und  die  underbindung  der  oberen  schil- 
drusenschlagader,  Heidelberg,  klin  ann.,  1825, 
i,  208-241. 

Meissner.  Gem  Deutsche  ztschr.  f.  geburtsh., 
Weimar,  1829,  iv,  423. 

Vado.     Aneurjsmaticae  historia   Jenae,   1831. 

Sur  le  goitre,  Paris,  1832. 

Heidenreich.  Med.  chir.-bl.  bayer  aerzte, 
Erlang.,  1843,  iv,  593-608. 

Albers.  Rhein  monatschr.  f.  prakt.  aerzte, 
Koln,  1848,  545-558. 

Diener.  Schweitz.  ztschr.  f.  med.-chir.  u. 
geburtsh.,  Zurich,  1848,  455. 

Cruveilhier.  Bull.  soc.  anat.,  Paris,  1854, 
xxix,  59. 

Paul.  Ztschr.  d.  Deutsch.  chirurgie  ver., 
Magdeb.,  1854,  viii,  i-ii. 

Velpeau.     Gaz.  d.  hop.,  Paris,  1857,  xxx,  339 

Sedillot.     Gaz.  d.  hop  ,  Paris,  1862,  xxxv,  102. 

Muller.  Eine  struma  vasculosa,  aerztl.  mitth. 
a  Baden,  Karlsruhe,  1862,  xvi,  114. 

Edwards.     Lancet,  London,  1864,  i,  666. 

Frobelius.     St.  Petersburg  med.  ztschr.,  1865, 

ix.  175- 

Tr.  Path.  Soc,  London,  1867  8,  xix,  428  430 ; 
1868-9,  XX,  390. 

Rosenbach.  Rehres,  Berlin  klin.  woch.,  1869, 
vi,38r. 

Muller.  J(  maisc  he  ztschr.  af  med.  u.  naturw  , 
Liepzig,  1871,  vi,  454. 

Girard.     Bordeaux  med.,  1872,  i,  368. 


Pasturand.  Bull.  soc.  anat.,  Paris,  1873,  xlviii, 
86. 

Maschka.  Plotzlicher  tod  erstickung  bedingt 
durch  hamorrhagien  in  ien  strume,  Vrtljschr.  f. 
d.  prakt.  heilk.,  Leipz.,  1877,  cxxxvi,  33. 

Low.  British  Med.  Journal,  London,  1878, 
1-932. 

Broka.  Jour,  de  med.  et  chirurgie  prat., 
Paris,  1876,  I,  255. 

Derbez.     Paris,  1880. 

Berger  and  Onimus.  Bull,  et  mem.  soc.  chir- 
urgie, Paris,  1881,  vii,  324. 

Jager-Luroth,     Strassburg,  1883. 

Boursier.  In  his  lee.  de  clin.  chir.,  1885  6» 
Paris,  1887,  21-42. 

Poisson.     Gaz.  med.  de  Nantes,  1885  6,  iv,  17. 

Peut.     Paris,  1885. 

Johns  Hopkins  Hospital  Bull.,  Baltimore,  1888- 

9.  i,  23- 

Osier.     Tr.   Path.  Soc,  Philadelphia  (1887-9), 

1891,  xiv,  684. 

Estor  and  Cudithac.    Montpelier  Med.  Suppl., 

1892,  i,  758  771,  2  pi. 

Simon.  Review  med.  de  I'est.,  Nancy,  1894, 
xxvi,  77 

Mermet.  Bull.  soc.  anat.,  Paris,  1896,  Ixxi, 
489  496. 

Bradley.  Journal  Exper.  Med.,  New  York, 
1896,  i,  401-418,  1  pi. 

Archibald.  Montreal  Med.  Journal,  1897,  xxv, 
780-788. 

Schaefer.  International  Clinic,  Philadelphia, 
1899  9^»  "»  224-227,  1  pi. 

ABSCKSS   (1843-1904). 

This  condition  of  the  thyroid  gland  is 
comparatively  rare,  primary  or  secondary, 
single  or  multiple,  varying  in  size,  shape 
and  location.  They  may  be  the  result  of 
injury,  inflammation  or  infected  cysts  of 
any  character,  and  they  may  rupture  into 
the  trachea  or  esophagus,  or  externally 
through  the  cutaneous  structures.  The 
abscess  may  involve  a  part  or  all  of  one  or 
more  lobes,  with  or  without  febrile  dis- 
turbances. General  infection  from  thyroid 
abscess  is  rare. 

Historical. — Dixon,  E.  H.,  1843,  de- 
scribed chronic  abscess  of  the  thyroid 
gland,  and  Velpeau,  1847,  made  a  difficult 
diagnosis  of  abscess  of  the  thyroid. 

Beck,  v.,  1851  ;  Wiegand,  1856,  and 
Staudenmayer,  1870,  each  described  an 
abscess  of  the  thyroid  gland. 

Englisch,  1877,  described  suppurative 
thyroiditis,  and  Pruvost,  1881  ;  Zwicke, 
1883,  and  Eder,  1883,  each  described 
suppurative  thyroiditis. 

Romain,  1886,  reported  suppurative 
thyroiditis  following  intermittent  fever, 
and  Musser,  J.  M.,  1887,  mentioned  an 
abscess  of  the  thyroid  gland  romplliiu  ing 
the  convalescence  of  typhoid  levcr. 

Lemarie,  1889,  described  inflammation 


184 


SURGERT  OF  THE   THYROID. 


and  suppuration  of  the  left  lobe  of  the 
thyroid,  and  Lydston,  1891,  reported  acute 
thyroiditis  with  abscess. 

BIBLIOGRAPHY. 

Dixon.  Boston  Med.  and  Surg.  Journal,  1843, 
xxviii,  15. 

Velpeau.     Gaz.  d.  hop.,  Paris,  1847,  ix,  727. 

Bernard.  Union  med.,  Paris  (1849  52),  1861, 
382  4. 

Beck.  Arch.  f.  physiol.  heilk.,  Stuttgart,  1851, 
X,  293  300. 

Wiegand.  Memorabilien,  heilLr.,  1856,  i.  No. 
9,  folio  I. 

Thirion.       Gaz.    d.  hop.,    Paris,    i860,    xxxiii, 

Staudenmayer.  Ztschr.  f.  wundarzt.  u.  ge- 
burtsh..  Stuttgart,  1870,  xxiii,  26-28. 

Block.  Ber.  d.  k.  k.  krankenh.,  Wieden,  1872, 
Wien,  187^,  140-2. 

Englisch.  Ber.  k.  k.  krankenannst.,  Rudolph- 
siftung  in  Wien,  1876;   1877,  372. 

Von  Mosetie-Moorhof.  Ber.  d.  k.k.  krankenh., 
Wieden,  1878,  Wim,  1879.  129  r33. 

Oulmont.       France    mcd.,    Paris,    1880,   xxvii, 

537- 

Lardiley.     Paris    1881. 

Pruvost.     Franc,  med.,  Paris,  1881,  ii,  711  13. 

Zwicke.  Charite  ann.,  1882,  Berlin,  1884,  ix, 
389. 

Eder.  In  his  aerztl.  ber.,  1883,  Wien,  1884, 
18  21. 

Romain.  Arch,  de  med.  et  phar.  mir.,  Paris, 
1886,  viii,  470. 

Musser.  Med.  Bulletin,  Philadelphia,  1887, 
ix,  67. 

Lemarie.  Bull.  soc.  anat.,  Paris,  1889,  xxxiv, 
313-315. 

Trotsch.     Erlangen,  1889. 

Rascol.     Paris,  1891. 

Lydston.  New  Orleans  Med.  and  Snrg.  Jour- 
nal, 1891-2,  xix,  815-817. 

Jeanselme.  Arch.  gen.  de  med.,  Paris,  1893, 
ii,  20  30. 

Jeanselme.     Gaz.  de   hop.,  Paris,   1895,  Ixviii, 

133-142- 

Gueniot.  Bull.  soc.  anat.,  Paris,  1897,  Ixxii, 
621 

Griffon.  Arch.  gen.  de  med.,  Paris,  1897,  ii, 
73941- 

Shaw.  Arch.  Pediat.,  New  York,  1899,  xvi, 
105. 

Manousos.     Pneumonique,  1900,  70  3. 

GANGRENE   (1898-I904). 

Gangrene  of  the  thyroid  gland  is  ex- 
ceedingly rare,  and  may  result  from  injury 
or  infection.  It  usually  appears  in  con- 
nection with  other  pathologic  changes. 
When  present  the  most  radical  surgical 
measures  should  be  adopted  (thyroidec- 
tomy). 

BIBLIOGRAPHY. 

Kerns.  Sloughing  of  the  Thyroid  Gland.  Dub- 
lin Med.  Press,  1839,  ii,  37, 

Damas.     Gaz.  hebd  ,  Paris,  1898,  iii,  1093. 

Sabbatini.  Raccoglitore  med.,  Forli,  1898,  i, 
193-5- 


TUBERCULOSIS    (1847-I904). 

Tuberculosis  of  the  thyroid  gland  is  ex- 
ceedingly rare  as  compared  with  other 
pathologic  changes  that  take  place  within 
it.  It  may  be  primary  or  secondary,  usu- 
ally primary. 

Little  is  known  concerning  the  pathol- 
ogy of  tuberculosis  of  the  thyroid  gland. 
The  gland  is  involved  in  about  i3  per 
cent,  of  the  cases  of  pulmonary  phthisis, 
and  usually  of  the  miliary  form  ;  it  origi- 
nates in  the  connective  tissue  between  the 
vesicles,  and  as  a  rule  the  gland  is  not  en- 
larged. 

Historical.  —  Albers,  1847,  observed 
tuberculosis  of  the  thyroid  gland,  while 
Quinlan,  1874,  gave  an  interesting  de- 
scription of  a  similar  case. 

Rolleston,  1896,  recorded  a  case  of  tu 
berculosis  of  the  thyroid  gland  rupturing 
into  the  esophagus. 

BIBLIOGRAPHY. 

Albers.  Rhein  monatschr.  f.  prakt.  aerzte, 
Koln,  1847,  663-668. 

Quinlan.  Irish  Hospital  Gazette,  Dublin, 
(1871  3),  1874,  "«'.  258. 

Chirari.     Med.  jahrb.,   Wien,  1878,  68  75,  i  pi. 

Fraenkel.  Arch.  f.  path,  anat.,  Berlin,  1886, 
civ,  58  72. 

Perry.  Transactions  Pathological  Society, 
London,  1890-1,  xlii,  798. 

Hegar,     Kiel,  1891. 

Schwartz.  Arch,  internat.de  laryngol.,  Paris, 
1894,  vii,  30-4. 

Rolleston.  Transactions  Pathological  Society, 
London,  1896  7,  xlviii,  197-200. 

Ivanoff.     Lyon,  1899-1900,  29,  43  p. 

SYPHILIS    (  1 887-1 904). 

Syphilis  of  the  thyroid  gland  is  rare, 
and  always  appears  in  the  form  of  gum- 
mata.  It  may  be  congenital  or  acquired, 
and  may  involve  the  gland  or  capsule 
alone  or  together,  primarily  or  by  exten- 
sion from  other  tissues. 

There  does  not  appear  to  be  any  definite 
knowledge  of  the  influence  of  syphilitic 
remedies  upon  gummata  of  the  thyroid, 
but  they  are  supposed  to  be  beneficial  in 
this,  as  in  syphilis  of  other  ductless  glands. 
If  their  administration  for  a  reasonable 
length  of  time  does  not  prove  beneficial, 
surgical  means  should  be  employed  for 
enucleation. 

Historical. — Clark,  1S97,  reported  a 
case  of  gumma  of  the  isthmus  of  the  thy- 
roid gland;  ulceration,  edema  of  the  lar- 
ynx, laryngo  tracheotomy,  recovery. 


SURGERr  OF  THE    TJU'ROID. 


185 


Dubois,  1897,  reported  one  of  syphilitic 
disease  of  the  thyroid  gland  treated  with 
thyroid  extract. 

Furst,  1898,  recorded  a  case  of  congeni- 
tal syphilitic  struma  of  the  thyroid  gland. 

BIBLIOGRAPHY. 

Fraenkel.  Deutsche  ined.  woch  ,  Leipzig, 
1887,  xxiii,  1035-8. 

Clarke.     Lancet,  London,  1897,  ".  389- 

Dubois.     Policlin.,  Brux.,  1897,  vi,  17. 

Kuttner.  Beitr.  z.  klin  chir.,  Tubing.,  1898, 
xxii,  517-5^0- 

Furst.     Berlin  klin.  woch  ,  1898,  xxxv,  1016. 

CANCER    (1813-I904). 

Historical. — Chomel,  18 13,  made  ob- 
servations on  cancer  of  the  thyroid  gland. 

Boileau,  1825,  made  observations  on 
cancer  of  the  thyroid  gland  terminating 
chronically. 

Gendron,  1833,  reported  on  cancer  of 
the  thyroid  gland  with  double  perforation 
of  the  esophagus  and  dilatation  of  the 
trachea. 

Poumet,  1837,  reported  cancer  of  the 
thyroid  gland,  obliteration  of  the  jugular 
vein,  ulceration  of  the  trachea  with  per- 
foration of  the  esophagus,  resulting  in 
fatal  hemorrhage ;  and  Ducros  one  of 
cancer  of  the  thyroid  gland  with  perfora- 
tion of  the  trachea  and  esophagus. 

Gaubrie,  1841,  and  Chassaignac,  1849, 
each  had  a  case  of  suffocation  produced  by 
prolonged  cancer  of  the  thyroid  gland. 

Duchec,  1853,  reported  a  cancer  of  the 
thyroid  body  with  perforation  of  the 
trachea.  -'' 

Moutard-Martin,  1856,  had  a  ca?e  of 
cancer  of  the  thyroid  ;  death  by  compres- 
sion of  right  pneumogastric  nerve 

Pitman,  1857,  reported  on  malignant 
disease  of  the  thyroid  body  from  apnea. 

Schuh,  1859,  reported  a  cancer  of  the 
thyroid  body,  and  Gosselin,  1861,  de- 
scribed a  cancerous  suffocative  goitre 
with  asphyxia. 

Boucher,  1867,  reported  a  cancer  of  the 
thyroid  gland  with  compression  of  the 
trachea. 

Williams,  1868,  reported  disease  of  the 
thyroid  gland  with  malignant  growth  in 
the  trachea. 

Payne,  1870,  reported  cancer  of  the 
thyroid  body  subsequent  to  ordinary 
bronchocele,  and  Harris,  1875,  reported 
malignant  tumor  of  thyroid  gland  in- 
volving the  glands  of  neck,  cancer  of 
esophagus  causing  obstruction  ;  death  from 
asthenia. 


Weir,  1876,  reported  cancer  of  thyroid 
gland  ;  death  from  asphyxia. 

Semon,  1881,  recorded  double  stenosis 
of  the  upper  air-passages,  i.e.,  bilateral 
paralysis  of  the  glottis-openers  and  com- 
pression of  the  trachea,  in  a  case  of  malig- 
nant tumor  of  the  thyroid  gland. 

Gulliver,  1885,  reported  on  malignant 
disease  of  thyroid  from  a  case  of  myx- 
edema. 

Hebb.  1888,  reported  a  case  of  cancer 
of  the  thyroid  isthmus  with  secondary 
deposits  in  the  kidneys,  lungs  and  verte- 
brae. 

Turner,  1889,  had  a  case  of  thyroid 
tumor  apparently  malignant  which  all  but 
disappeared  after  tracheotomy ;  renewed 
growth  in  an  undoubtedly  sarcomatous 
form. 

Pollosson,  1889,  made  observations  on 
cancer  of  the  thyroid  with  congestion  of 
the  esophagus. 

Willett,  1891,  had  a  case  of  malignant 
disease  of  the  thyroid  gland  involving  the 
esophagus  and  cervical  vertebra?,  with 
a  deposit  of  thyroid  tissue  in  the  bone. 

Hutchinson,  1895,  reported  on  broncho- 
cele with  malignant  growths  in  bone. 

Guinon  et  Bufnoir,  1898,  reported  on 
cancer  of  the  thyroid  gland  penetrating 
the  trachea;  death  by  suffocation. 

Talihefer,  1898,  reported  on  chronic  in- 
flammation of  the  thyroid  gland,  resulting 
in  cancer. 

BIBLIOGRAPHY. 

Chomel.  Jour,  de  med.  chirurgie  pharm., 
Paris,  18 f 3,  xxviii,  339-343- 

Boilleau.  Arch.  gen.  med.,  Paris,  1825,  ix, 
16-21. 

Gendron.  Bull.  soc.  anat.,  Paris,  1833,  2  ed., 
1849,  viii.  34-45- 

Poumet.  Bull.  soc.  anat.,  Paris,  1837,  xii, 
327  336. 

Ducros.     Bull.  soc.  anat  ,  Paris,  1838,  xiii,  98. 

Gaubrie.  Bull.  soc.  anat.,  Paris,  1841,  xvi, 
123-136. 

Dutton.  Prov.  Med.  and  Surg.  Journal,  Lon- 
don, 1845,  ^'>  7- 

Chassaignac.  Gaz.  d.  hop.,  Paris,  1849,  i, 
488. 

Qiiinlin.  Proc.  Path.  Soc,  Dublin,  1852  3, 
iii,  287. 

Legendre.  Bull.  soc.  aniit.,  Paris,  1852,  xxvii, 
470. 

Duchek.  Vrtljschr.  f.  d.  prakt.  heilk.,  Prague, 
1853,  i,  hft.  30. 

Noutard-Martin.  Bull.  soc.  med.  d.  hop., 
Paris,  1856  8;  1884,  iii,  2433. 

Pitman.  British  Med.  Journal,  London,  1857, 
ii,  581. 

Von  Bruns.  Deutsche  klinik.,  Berlin,  1859, 
xi,  83,  122,  129,  145. 

Gosselin.   Gaz.  d.  hop.,  Paris,  1861,  xxxiv,  131. 


1 86 


SURGBRT  OF  THE    THTRUID. 


Stoddard.  Med.  and  Surg.  Reporter,  Phila- 
delphia,  1861,  vi,  lO!. 

Krebs  Aerztl.  der.  d.  k.  k.  alig.  krakenh.  zu 
Wien,  1862;  1863,  136. 

Boucher.     Bull.  soc.    anat.,  Paris,   1867,    xlii, 

Lucke.  Arch.  f.  klin.  chirurgie.  Berlin,  1867, 
viii,  88  93. 

Stokes.  Dublin  Journal  Med.  Science,  1868, 
xlvi.  220. 

Williams.  Tr.  Path.  Soc,  London,  1868  9, 
XX.  394  397- 

Church.  Tr.  Path.  Soc,  London,  18689,  ^x, 
392  394' 

Payne.  Tr.  Path.  Soc,  London,  1870  71, 
xxii,  283-354. 

Harris.  St.  Bartholomew's  Hospital  Report, 
London,  1875,  263  265 

Mo,  G.     Osservatore,  Torino,  1875,  xi,  358. 

VVeir.  Med.  Record,  New  York,  1876,  xi, 
146. 

Meissner.  Verm,  chirurgie  schrift,  Berlin  u. 
Stettin,  1876,  i,  299. 

Rouse.  St.  George's  Hosp.  Report,  1877  78, 
London,  1879,  ix,  275. 

Ballet.  Bull.  soc.  anat.,  Paris,  1878,  liii,  116- 
118. 

Deutsche  ztschr.  f.  chirurgie,  Leipzig,  1880- 
81,  xiv,  25  49. 

Sands.     Med.    Record,   New    York,   1881,  xx, 

303 

Polaillon.  Ann.  d.  mal.  de  I'oreille  et  du 
larynx,  Paris,  1881,  vii,  340343. 

Senion.  Tr.  Path.  Soc,  London,  1881-2, 
xxxiii,  38  48    I  pi. 

Gerster.  Med.  News,  Philadelphia,  1882,  xli, 
740. 

Brann.  Verhandl.  d.  Deutsch.  gellsch.,  Ber- 
lin, 1882,  xi,  pt.  2,  1-65,  I  pi. 

Bircher.  Samml.  klin.  vortr.,  Leipzig,  1882, 
No.  222;  Chirurgie,  No.  71  (1893- 1896),  2  pi. 

Mdthieu.  Progres  med.,  Pans,  1882,  x,  263- 
266. 

Krishaber.  Ann.  d.  mal.  de  I'oreille  et  du 
larynx,  Paris,  1882,  viii,  239  248. 

Puzey.  British  Med.  Journal,  London,  1883, 
ii,  430. 

Ann.  d  mal.  de  I'oreille  et  du  larynx,  1883,  ix, 
12  18. 

Coulon.     Paris,  1883. 

Giraudeau.  Rev.  de  med.,  Paris,  1884,  iv, 
io2-io8. 

Jenaischo.  ztschr.  f.  med  ,  u.  naturw.,  Leipzig, 
481-495. 

Webster.  Weekly  Med,  Review,  Chicago, 
1885,  xi,    176. 

Gulliver.  Tr.  Path.  Soc,  London,  1885  6, 
xxxvii,  511  513. 

Stoker.  Tr.  Path.  Soc,  London,  1886-7, 
xxxviii,  396. 

Strecker.     Wurzburg,  1887. 

Wien  med.  woch.,  1888,  xxxviii,  673  677. 

Mason.  Brooklyn  Med.  Journal,  1888,  i,  229- 
232. 

Hayem.  M.  Parmentier  Bull,  et  mem.  soc, 
medical  hospital,  Paris,  1888,  v,  3^3  348. 

Rollet.     Gaz.  med.  de  Paris,  1888, v,  234-247. 

Pic.     Lyon  med.,  1888,  Iviii,  307  311. 

Parmentier  and  Hartmann.  Bull.  soc.  anat., 
Paris,  1888,  Ixiii,  947-953. 

Hebb.  Westminster  Hospital  Report,  London, 
1838,  iv,  189  192,  I  pi. 


Wolfenden.  Med.  Press  and  Circular,  Lon- 
don, 1888,  xlvi,  591-594. 

Orcel.     Lyon,  1889. 

PoUosson.  Province  med.,  Lyon,  1889,  iii,  133. 

Hutchinson.  British  Med.  Journal,  London, 
1889,  ii,  128. 

Albert.   Allg.  wien.  med.  ztg.,  1889,  xxxiv,  55. 

Turner.  Tr.  Clin.  Soc,  London,  1889-90, 
xxiii,  226-231. 

Schmidt.     Wurzburg,  1890. 

Schutt.     Kiel,  1891. 

Busachi.     Gaz.  d.  osp.,   Napoli,  1891,  xii,  651. 

Porte.     Lyon  med.,  1891,  Ixvii,  402. 

Petrakides.     Wurzburg,  189' 

Willet.  Tr.  Path.  Soc,  London,  1891-2, 
xliii,  144. 

Senion.  Med. -Chirurgie  Tr.,  London,  1892-3, 
Ixxvi,  375  390. 

Chabory.  Rev.  de  laryngol.,  Paris,  1893,  xiii, 
490  492. 

Poncet.  Gaz.  hebd.  de  med.,  Paris,  1893,  xi, 
319  321. 

Schmalbach.     Wurzburg.  1893. 

Jahresb.  u.  d.  Chirurgie  abt.  d.  spit,  zu  Basel, 
-893;  1894,  50. 

Morris.     Lancet,  London,  1894.  i,  332-334. 

Letulle.     Presse  med.,  Paris,  1894,  269-272. 

Botticher.     Halberstadt,  1894. 

Brindel  et  Liaris.  Jour,  de  med.  de  Bordeaux, 
vi,  XXV,  4.'3-425. 

Hutchinson.  Arch.  Surgery,  London,  1895, 
vi,  911. 

Bertrand,  Joseph.     Lyon,  1895,  'S^  P- 

Friedland.  Prague  med.  woch.,  1896,  xxi, 
103 

Limacher.     Berlin,  1898 

Guinon  et  Bufnoir.  Bull,  et  mem.  soc  med. 
hop.,  Paris,  1898,  xxv,  253. 

Talihefer.  Rev.  de  chirurgie,  Paris,  1898,  xviii, 
224-231. 

Hellendall.  Deutsche  med.  woch.,  Leipzig  u. 
Berlin,  1899,  xxv,  222. 

Carrell-billard.  Lyon,  1900,  N.  147,  303  p., 
6  pi.,  6  fig. 

Winter.     Breslau,  1900 

Gruie.     Lyon,  1899  1900,  91  p. 

Muscatello  et  Cancitano.  Riforrna  med  ,  Pa- 
lermo, 1900,  ii,  508. 

Balacesco.  Bull,  et  mem.  soc.  de  chirurgie  de 
Bucarest,  1900,  iii,  95-96. 

CARCINOMA     (1844-1904). 

Carcinoma  of  the  thyroid  gland  is  fre- 
quent, primary  or  secondary,  usually  pri- 
mary, and  may  involve  one  or  more  lobes, 
of  any  variety,  hard,  soft  or  cystic,  and 
of  slow  or  rapid  growth. 

Historical. — Hawkins,  1844,  reported 
cases  of  carcinoma  of  the  thyroid  gland. 

IMuller,  187 1  ;  Eberth,  1872;  and  Cor- 
nil,  187 ;i,  each  report  an  epithelioma  of 
the  thyroid. 

Von  Schrotter,  1880,  and  Demme,  R., 
1880,  mentioned  a  medullary  carcinoma 
of  the  thyroid. 

Mayor,  1881,  reported  a  carcinomatous 
tumor  of  the  thyroid  with  secondary 
nucleus  in  the  brain  and  lung. 


SURGERY  OF  THE   THYROID. 


187 


Ofer,  1884,  described  a  perforation  of 
the  thyroid  with  carcinoma. 

Weinlechner,  1S88,  mentioned  a  medul- 
lary carcinoma  of  the  thyroid  with  sec- 
ondary carcinoma  of  the  lung. 

Banti,  1889,  describes  a  primitive  carci- 
noma. 

Baginsky,  1891,  reported  a  carcinoma 
of  the  thyroid  gland. 

Branca  et  Menier,  1896,  reported  a  case 
of  tumor  of  the  thyroid  with  epithelioma 
development  ;   death  by  asphyxia. 

Galeotti,  1896;  Della-Vedova,  1896; 
andEwald,  1896,  each  reported  carcinoma 
of  the  thyroid  glands. 

Berger,  1S97,  described  an  epithelioma 
of  the  thyroid  gland. 

Frank  and  Guntermann,  1897,  men- 
tioned a  cystic  carcinoma  of  the  thyroid. 

Le  Fur,  Buffnoir  et  Milian,  Hobbs  et 
Beguin,  1898,  each  report  an  epithelioma 
of  the  thyroid  gland. 

Banti,  1889;  Baginsky,  1891  ;  andMott, 
1899,  each  had  a  case  of  primary  carci- 
noma of  the  thyroid  with  secondary  infil- 
tration of  the  lymphatic  glands. 

BIBLIOGRAPHY — PRIMARY    CARCINOMA. 

Hawkins.  Med.  Chirurgie  Transactions,  Lon- 
don, 1844.  xxvii,  25-^7. 

Brown.  Med.  chirurgie  Transactions,  Lon- 
don, 1844,  xxvii,  3740. 

Neiatun.  Encephaloide  du  corps  thyroid  re- 
marquable  par  la  rapidite  de  son  developement, 
Gaz.  d.  hop.,  Paris,  1849.  287. 

Seitz.     Deutsche  klinik,  Berlin,  1856,  viii,  403- 

405- 

Werner.  Ztschr.  f.  wundarzte  u.  geburtsh., 
Stuttgart,  1869,  xxii,  161-170. 

Billroth.  In  his  chirurgie  klin.,  Wien,  187 1-6; 
Berlin,  1879,  184. 

Eberth  Arch.  f.  path,  anat.,  Berlin,  1872, 
Iv,  254. 

Holdt.     Clinic,  Cincinnati,  1873,  i^-  26. 

Cornil.  Compt.  rend.  soc.  biol.,  Paris,  1875, 
ii,  273  280. 

Eppinger.  Vrtljschr.  f.  d.  prakt.  heilk,  Leip- 
zig, 1875,  cxxvi,  13-17. 

Gemniel.      Freiburg,  i,  Br..  1875. 

Menzel.  Resoc.  san.  d.  osp.  di  Trieste,  1876, 
ii,  97- 

Socin.  Jahresb.  u.  d.  chirurgie,  abth.  d.  spit, 
zu  Basel,  1876,  26. 

Von  Schrotter.  Ber  d.  k.  k.  kranrenannst, 
Rudolph  Siftung,  in  Wien,  1879;  1880,  337. 

Smith.  British  Med.  Journal,  London,  1880, 
i.  479- 

Englisch.  Ber.  d.  k.  k.  krankenanst,  Rudolph- 
Siftung  in  Wien,  1881  ;   1882,  291. 

Zwiike.     Charite  Ann.,  Berlin,  1882,  vii,  506. 

Osner.     Wien.  med.  bl.,  1884,  ^i'>  '5^8  70. 

Carrington.  Tr.  Path.  Soc,  London,  1885-6, 
xxxvii,  508  511. 

Aerzti.  ber.  d.  k.  k.  allg.  krankenh.  zu  Wien, 
i886;  1888,  15- 17. 


Cases.  Jahresb.  u.  d.  chirurgie,  abth.  d.  spit, 
zu  Basel,  1886;   1887,  36;   1889.  57. 

In  Feeder,  aerzti.  ber.,  1888;  Wien,  1889,  24. 

Banti.  Arch,  di  anat.  norm,  e  patol.,  Firenze, 
1889  90,  V,  131 -142. 

Scheinmann.  Deutsche  med.  woch.,  Leipzig, 
1890,  xvi,  263-265. 

Journal  Laryngol  ,  London,  1890.  iv,  50-3. 

Baginsky.  Veroffentl.  d.  hufeland.  gesellsch. 
in  Berlin,  Vortr.,  1891-2,  86  91. 

Pet  Rakides.     Wurzburg,  1892. 

Podbelsky.  Ueber  das  vorkommen  des  col- 
loides  in  den  lyrnphgefassen  der  strumos  erkrank- 
ten  menschlichnen  schilddruse,  Prague  med. 
woch.,  1892,  xvii,  197,  211. 

Branca  et  Menier.  Ann.  d.  mal.  de  I'oreille 
du  larynx,  Paris,  1896,  xxii,  476,  485. 

Galeotti.  Arch.  f.  mikr.  anat.,  Bonn,  1896, 
xlviii,  305-328,  I  pi. 

Della-Vedova.  Atti  d.  assoc.  med.,  Lomb., 
1895;   Milano,  1896,  381-386. 

Ewald,     Wien  klin.  woch.,  189,  ix,  1866. 

Berger.  Assoc,  franc,  de  chirurgie  proc-verb., 
Paris,  1897,  xi,  15-37. 

Frank  and  Guntermann.  Leonard's  Illustrated 
Med.  Journal,  Detroit,  1897,  xvii,  12. 

Frank  and  Guntermann.  Medicine,  Detroit, 
i8q7,  iii,  33-36. 

Le  Fur.  Bull.  soc.  anat.,  Paris,  1896,  Ixxiii, 
790  2. 

Hobbs  et  Beguin.  Rev.  internat.  de  rhinol., 
otol.  et  laryngol.,  Paris,  1898,  ix,  261-3. 

Mott.  Med.  Press  and  Circuh^.r,  London, 
1899,  xlvii,  245. 

CYLINDRICAL    EPITHELIOMA. 

MuUer.  Jenaische  ztschr.  f.  med.  u.  naturw., 
Leipzig,  1871,  vi,  456-475. 

MEDULLARY    CARCINOMA. 

Demme.  Med.  ber.  d.  thatigk.  d.  Jennen'schen 
Kinders.  in  Berne,  1879;  1880,  xxvii,  5560,  i  pi. 

Weinlechner.  Aerzti.  der  d.  k.  k.  allg.  kran- 
ren.  zu  Wien,  1886;   1888,  213. 

Mayor.  Bull.  soc.  anat.,  Paris,  1881,  Ivi, 
723-727. 

SARCOMA    (1838-I9O4). 

Sarcoma  of  many  forms  are  found  in 
the  thyroid  gland,  both  of  primary  and 
secondary  origin,  cystic  or  solid,  single  or 
multiple,  fixed  or  movable,  rapid  or  slow 
in  their  development,  varying  in  size, 
with  or  with®ut  glandular  involvement. 
They  usually  appear  in  early  life,  without 
reference  to  sex  or  any  known  cause. 

Historical. — Raynaud,  1838,  reported 
an  encephaloidic  sarcoma  with  contents  in 
chest. 

Kuchler,  i86j,  described  cystosarcoma 
of  the  thyroid  gland. 

Thorl,  1866,  also,  mentioned  a  cysto- 
sarcoma of  the  thyroid  gland. 

Muller,  1871,  reported  a  spindle-celled 
sarcoma  with  consumption. 

Doleris,  1876,  reported  a  primary  sar- 
coma with  compression  of  vocal  cord. 


SURGEin'  OF  THE    THTROID. 


Boechat,  1877,  described  the  spindle- 
celled  sarcoma. 

Kaufmann,  1878,  contributed  his  study 
of  primary  sarcoma  of  thyroid  gland. 

Fornari.  1S79,  aspirated  a  primary  sar- 
coma of  thyroid  gland. 

Heath,  1879,  had  a  case  of  spindle- 
celled  sarcoma  of  the  thyroid  involving 
larynx  ;  secondary  deposit  ;   death. 

Braun,  1879,  contributed  to  the  anatomy 
of  the  lympho  -  sarcoma  of  the  thyroid 
gland. 

Geffrier.  j8So,  reported  a  melanotic 
sarcoma  of  the  thyroid  with  pneumogas- 
tritis. 

Mathieu,  1881,  reported  a  primary  sar- 
coma of  the  thyroid  gland. 

Koch,  1883,  contributed  his  study  of 
primary  sarcoma  of  the  thyroid  gland. 

Bowlby,  1S84,  reported  an  infiltrating 
sarcoma  of   the  thyroid. 

Paget,  1886,  reported  a  malignant  dis- 
ease of  thyroid  (round  celled  sarcoma). 

Pitt,  1887,  reported  a  sarcoma  of  left 
lobe  of  thyroid  growing  round  the  eso- 
phagus and  invading  the  left  internal 
jugular  vein  and  left  vagus;  ante  mortem 
clot  on  right  side  of  heart  containing 
growth. 

Shattock,  1887,  reported  hypertrophy 
of  an  accessory  thyroid  gland  in  a  case  of 
spindle-celled  sarcoma  of  the  thyroid. 

Bryant,  1891,  made  a  similar  report. 

Labbe,  1895,  reported  a  primary  sar- 
coma with  tuberculosis. 

Gatti,  1895,  mentioned  the  rapid  de- 
velopment of  a  sarcoma  of  the  thyroid 
gland  caused  by  infection  from  a  strepho- 
tome. 

Rabe,  1897,  reported  a  primary  sarcoma 
of  the  thyroid  gland  with  pneumonia; 
death  by  infection. 

Franckel,  1897,  mentioned  a  melanotic 
sarcoma  of  the  thyroid. 

Kummer,  1898,  described  a  sarcoma- 
adenoid  of  the  thyroid  gland. 

BIBLIOGRAPHY PRIMARY    SARCOMA. 

Doleris.  Bull.  soc.  anat.,  Paris,  1876,  ii, 
225  227. 

Kaufmann.  Deutsche  ztschr.  f.  chirurgie, 
Leipxig.  1878  9.  xi,  401-485,  i  pi. 

Mathieu.       Bull    soc     anat.,    Paris,    1881,    Ivi, 

370-5. 

Koch.     Ann.    H.    mal.   de   Toreille    du    larynx, 

Paris,  1883,  ix,  195-9 

Kobler.      Wien  med.  woch.,  1896,  xxxvi,  295, 

344. 

Piit.  Tr.  Path,  soc,  London,  1886-7;  1887, 
xxxviii,  398. 


Sharpies.  Univ.  Med.  Magazine,  Philadelphia. 
1889  90,  ii,  422. 

Cohen.  New  York  Med.  Journal,  1889,  i. 
1468. 

Koch.     Luxembourg  (n.  d  ). 

Labbe.  Bull.  soc.  anat.  de  Paris,  1895,  1*^> 
308  II. 

Gatti.  Rev.  de  chirurgie,  Paris,  1895,  ^^> 
618  625. 

Hesse.     Wurzburg,  1895 

Rabe.  Bull.  soc.  anai.,  Paris,  1897,  ixii, 
597  605. 

Shears.     Clinique,  Chicago.  1898,  xix,  291-3. 

Stengel.  Tr.  Path.  Sgc,  Philadelphia,  1898, 
xviii,  425. 

Rajmond.  Bull.  acad.  de  med.,  Paris,  1838  9, 
i".  573- 

CYSTO- SARCOMA. 

Kushler      Deutsche  klinik,  1861,  xiii,  422. 
Thorl.   Ztschr.  f.  nat.  med.,  Leipzig  u.  rleidel- 
berg,  1866,  3  R,  xxvi,  180-185,  i  pi. 

SPINDLE- CELLED    SARCOMA. 

MuUer.  Jenaische  ztschr.  f.  med.  u.  naturw., 
Leipzig,  1871,  vi,  476-480. 

Boechnt.  Bull.  soc.  med,  de  la  Suisse,  Rome, 
Lausanne,  1877,  xi,  39-42. 

Heath.  Med.  Times  and  Gazette,  London, 
1879,  ii,  663. 

Shattuck.  Tr.  Path.  Soc,  London,  1884-5, 
xxxix,  229-237,  I  pi. 

MELANOTIC    SARCOMA. 

Geffrier.     Gaz.  d.  hop.,  Paris,  1880,  liii.  337  9. 
Franckel.     Prague  med.  woch.,  1897,  xxii,  321. 

FIBRO-SARCOMA. 

Bowlby,  Tr.  Path.  Soc,  London,  1884  5, 
xxxvi,  426  423. 

ROUND   CELLED    SARCOMA. 

Paget.  Tr.  Path.  Soc,  London,  18867, 
xxxviii,  367. 

Bryant.     International    Clinic,     Philadelphia, 

ii,  123  5- 

Kummer.  Rev.  de  med.  de  la  Sbisse  Rome, 
Geneve,  1898,  xviii,  702  709. 

PATHOLOGY. 

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SURGERY  OF  THE   THYROID. 


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SURGERY  OF  THE    THYROID. 


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EXPERIMENTAI.    (1884-I9O4). 

Historical . — Tizzoni,  1884,  made  in- 
teresting experiments  upon  the  thyroid 
gland  to  determine  its  physiopathology. 

Schwartz,  1888,  removed  the  thyroid 
gland  in  animils  to  determine  the  effects 
of  extirpation  of  the  thyroid  gland;  Neu- 
meister,  1888,  made  a  series  of  experi- 
ments pertaining  to  the  histology  and  re- 
generation of  the  thyroid  gland,  and 
Kemperdick,    1889,  experimented  on  the 


eliminating  properties  of  the  thyroid 
gland. 

Lannelongue,  1890,  made  experiments 
in  transplanting  segments  of  the  thyroid 
gland. 

Moussu,  1892,  experimented  with  the 
thyroid  gland  to  observe  its  function  and 
influence  upon  cretinism. 

Godart,  1894,  reported  his  researches  in 
transplanting  thyroid  tissue. 

Jacobs,  1894;  Enderlin,  1898;  and  Sul- 
tan, 1898,  each  rhade  many  experiments 
pertaining  to  transplantation  of  thyroid 
tissue. 

BIBLIOGRAPHY. 

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Kemperdick.     Bonn,  1889. 

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1897,  Ixvii,  505  540. 


196 


SURGERT  OF  THE   THYROID. 


Gluzinski  et  Lemberger.  Bull,  international 
acad.  d.  sc.  de  Cracovie,  1897,  194-198. 

Fraina,  R.  Policlinic,  Roma,  1898,  v,  sez. 
med.,  441-469. 

Roger  et  Gamier.  Compt.  rend.  soc.  oiol., 
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anat.,  Jena,  1898,  ix,  388390. 

Roger  et  Gamier.  Presse  med.,  Paris,  1900, 
ii.  93-97.  7  fig- 

MEDICAL  TREATMENT    (1794-I9O4). 

Medical  treatment  of  hypertrophy  of 
the  thyroid  gland  has  been  both  local  and 
internal,  and  the  two  combined,  with 
more  or  less  beneficial  results,  and  with 
out  any  knowledge  of  their  fnodus  oper- 
andi or  any  tangible  logic  for  their  em- 
ployment. 

Strophanthin  has  been  extensively  em- 
ployed, especially  in  cases  of  exophthalmic 
goitre  in  which  very  gratifying  results 
were  obtained.  It  was  supposed  to  more 
or  less  influence  the  heart's  action,  and  in 
that  way  become  beneficial. 

Animal  extracts  have  been  employed 
with  great  benefit  in  both  exophthalmic 
and  parenchymatous  goitre  giving  better 
results  than  any  other  form  of  treatment. 
They  do  not  cure,  they  only  lessen  the  size 
of  the  neoplasm  in  a  certain  number  of 
cases,  and  they  are  therefore  commend- 
able as  a  palliative  measure. 

Fresh  glands  on  ice  do  not  produce 
toxic  etTects,  and  the  best  results  are  in 
chlorotic  patients  when  raw  sheep's  glands 
are  used.  Medicative  measures  not  being 
curative,  cannot  be  recommended. 

Historical. — Dubouloz,  1855, considered 
the  therapeutics  of  goitre. 

Monat,  1857,  wrote  on  the  use  of  iodide 
of  mercury  in  combination  with  the  rays 
of  the  sun  for  the  cure  of  goitre. 

Grandjoin.  1858,  employed  the  use  of 
iodine  in  connection  with  salines  in  the 
treatment  of  goitre. 

Frodsham,  i860,  treated  goitre  by  the 
external  use  of  mercury,  while  O'Connor, 
i860,  successfully  treated  goitre  by  large 
doses  of  bromide  of  potassium  and  liquor 
potass- a;. 

Guptill,  1874,  treated  exophthalmic 
goitre  successfully  with  iodo-bromide  of 
calcium,  and  Woakes,  1879,  used  fluoric 
acid. 

Boechat,  1880,  employed  iodoform,  and 
Fussell,  1S87,  Lugol's  solution  in  treating 
goitre. 


Born,  1892,  applied  a  solution  of  nitrate 
of  silver  externally  in  the  treatment  of 
goitre. 

Putnam,  1893,  reported  his  observations 
on  the  use  of  sheep's  glands  for  goitre, 
and  Alekseyeff,  1895,  record?  two  success- 
ful cases  of  goitre  treated  with  sheep's 
thyroid. 

Britan,  1897,  treated  goitre  with  a  com- 
bination of  "  iodo-thyrine." 

BIBLIOGRAPHY. 

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Co!-ta.  Intorno  alle  cause  del  gozzo  ed  ai 
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Jaeger.  Ueber  die  anwendung  der  hydrargy- 
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Shannon.     British  Med.  Journal,  London,  1879, 

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1879  81,  V,  289  298. 


SURGERT  OF  THE   TIITROID. 


197 


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Hayssen.  C)intment  for  Goitre,  No.  4  8  717, 
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Brown.  North  American  Practitioner,  Chi- 
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639  643. 

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490  500. 

Putnam.  American  Journal  Medical  Society, 
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613,  1895,  xliii,  1205. 

Berkley.  Johns  Hopkins  Hospital  Report, 
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Angerer.  Munchen  med.  woch.,  1894,  xlv, 
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Macphail,  S.  R.  and  L.  C.     Lancet,  London, 

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894. 

Anderson.  Arch.  f.  anat.  u.  entwicklinggesch., 
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Jaboulay.  Arch,  d'an  hop.  crim.,  Lyon  and 
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AlekseyefT.  Med.  obsh.,  Mosk.,  1895,  xliii, 
704-707. 

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Review  medical,  Louvain,  1895-6,  xiv,  496  498. 

Firbas.  Zur  klinik  und  therapie  der  schild- 
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1895,  xii,  7II-7I4- 

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185-240. 


Pizzini.  Atti  d.  assoc.  med.-lomb.,  Milano, 
1895,  56-65. 

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1895,  'xii,  302-309. 

Robison.  North  American  Practitioner,  Chi- 
cago, 1895,  vii,  403-406. 

White.  Maryland  Med.  Journal,  Baltimore, 
1895  6,  xxxiv,  37-40. 

Grant.  Cincinnati  Med.  Journal,  1896,  xi,  157- 
162. 

Notkin.  Thyroid  Gland  Normally,  Pathologi- 
cally and  Therapeutically  Considered.  Russk. 
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burg, 1896,  i,  530-547. 

Bacalossi.  Settimanna  med.  d.  sperimentale, 
Firenz, 1896,  i,  347-351. 

Lamari.  Review  clin.  e  terap.,  Napoli,  1896, 
xviii,  228-J32. 

Stabel.  Zur  schilddrusentherapie.  Berlin  klin. 
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Branthomme.     Frnnce  med.,  Paris,  1896,  xliii, 

51- 

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Paris,  1896,  xliii,  327-329. 

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delphia, 1896, Ixxiv,  132. 

Reinbach.  Jahresb.  d.  schles.  gesellsch.  f. 
vaterlcult  (1895),  Bresl.,  1896,  Ixxiii,  i  abth.. 
Medical  Section,  88. 

Gaz.  d.  osp.,  Milano,  1896,  xvii,  195. 

Poyet.  Gaz.  med.  de  Picardie,  Amiens,  1896, 
xiv,  126-128. 

Irsai,  Vas  and  Gara.  Deutsch.  med.  woch., 
Leipzig  u.  Berlin,  1896,  xxii,  439.441. 

Kijewski.  Gaz.  lek.,  Warazawa,  1896,  xvi, 
989-998. 

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178. 

Reyes.     Riforma  med  ,  Napoli,  1896,  xii,  pt.  2, 

314  317- 

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SURGERY  OF  THE   THYROID. 


Hayes.     Tr.   Royal  Medical  Society,  Ireland, 
1898,  xvi,  54-56. 
Craig.     Western  Med.  Review,  Lincoln,  Neb., 

1898,  iii,  371. 

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zig, 1900,  Ixxi,  pt.  2,  2  hfte,  124-127. 

ELECTRICAL  TREATMENT   (1860-I904). 

Electricity  of  various  kinds  has  been 
extensively  employed  for  all  kinds  and 
degrees  of  disease  of  the  thyroid  gland, 
with  more  or  less  beneficial  results. 

Galvanism  and  the  electro  cautery  have 
been  given  preference  ;  however,  the  use 
of  any  form  of  electricity  has  not  been 
satisfactory.  In  point  of  fact  no  definite 
claim  can  be  accorded  this  form  of  treat- 
ment at  this  time.  There  being  so  many 
cases  that  recover  spontaneously  it  is  diffi- 
cult to  ascribe  recovery  to  the  application 
of  any  form  of  electricity  in  a  given  case  ; 
therefore,  no  form  of  electricity  should  be 
employed  in  the  treatment  of  goitre.  It 
is  more  injurious  than  beneficial,  especially 
in  the  event  of  subsequent  thyroidectomy, 
as  it  causes  more  or  less  adhesions,  which 
renders  the  operation  more  difficult. 

Historical. — Schuh,  i860,  applied  gal- 
vanism to  an  enlarged  thyroid  gland,  and 
he  was  followed  by  Lamm,  in  1S70,  with 
the  same  method. 

Wahltuch,  187 1,  successfully  treated  a 
case  of  bronchocele  by  electrolysis  and  the 
subcutaneous  injections  of  iodine. 

Meyer,  1874,  applied  galvanism  to  the 
sympatheticus  in  a  case  of  exophthalmic 
goitre. 

Smith,  1875,  cured  a  cyst  of  the  thyroid 
gland  by  electrolysis  after  injections  had 
failed. 

Erienmeyer,  1877,  experimented  ex- 
tensively with  the  application  of  galvan- 
ism to  the  sympatheticus  in  exophthalmic 
goitre. 

Niepoe,  1877,  applied  the  electro-cau- 
tery to  an  enlarged  thyroid  gland. 

Rockwell,  1879,  wrote  on  the  value  of 
the     galvanic     current    in    exophthalmic 


goitre  as  illustrated  in  the  treatment  of 
four  cases,  and  Poole,  1880,  considered  the 
subject  of  electricity  as  a  paralyzing  agent 
in  the  treatment  of  exophthalmic  goitre. 

Hadden,  1887,  treated  exophthalmic 
goitre  with  the  continuous  current,  and 
Lacaille,  1889,  employed  the  negative 
pole  to  hypertrophied  goitre. 

Lloyd,  1890,  contributed  his  study  on 
the  g  ilvano  puncture  in  a  case  of  goitre. 

Juettner,  1890,  wrote  on  the  thyroid 
gland,  the  neurotic  character  of  its  en- 
largements, and  the  relative  value  of  the 
galvanic  current  in  their  treatment. 

Wile,  1893,  recorded  a  case  of  goiire 
cured  by  galvanism  and  syrup  of  hydriodic 
acid. 

Dickson,  1892,  made  a  contribution  to 
the  electrical  treatment  of  cystic  goitre, 
hydrocele  and  psoriasis. 

Bordier,  1894,  reported  his  observations 
on  the  use  of  faradistn  in  the  treatment  of 
exophthalmic  goitre. 

King,  1898,  and  Bonatdi,  1900,  have 
contributed  some  very  interesting  observa- 
tions on  the  treatment  of  exophthalmic 
goitre  with  galvanism. 

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Lamm.     Stockholm,  1870,  29. 

Wahltuch.  Med.  Times  and  Gazette,  London, 
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Meyer.  Berlin  med.  gesellsch.  (1871  3),  1874, 
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oli,  1882,  vii,  316  321 

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SURGERY  OF  THE   TUT  ROW. 


19$ 


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128. 


GENERAL  SURGERY    (1769-I9O4). 

In  the  chapter  on  general  surgery  must, 
necessarily,  be  included  all  the  operations 
the  character  of  which  is  in  doubt. 

The  writings  are  so  voluminous  that  it 
is  impossible  to  refer  to  all  of  them  for  a 
minute  description  of  the  character  of  the 
operation.  There  is,  however,  enough 
available  material  to  consume  more  time 
than  the  average  investigator  cares  to 
give. 

The  object  of  this  compilation  has  been 
to  make  the  work  already  done  as  concise 
as  possible  for  those  who  are  busily  en- 
gaged ;  by  doing  so  more  definite  conclu- 
sions can  be  obtained. 

The  subject  in  general  is  one  that  seems 
to  have  been  known  to  but  a  few,  while, 
in  fact,  if  it  had  been  more  generally 
known  the  great  achievements  that  have 
been  accomplished  would  not  be  confined 
to  the  comparatively  few  operators  who 
are  to  be  so  highly  complimented  for  their 
work. 

The  want  of  progress,  many  times,  in  a 
given  direction  is  due  to  a  want  of  knowl- 
edge of  what  has  been  accomplished. 

Historical. — Prosser,  1769,  reported  an 
account  and  method  of  cure  of  the  broncho- 
cele  or  Derby  neck,  to  which  are  subjoined 
remarks  on  some  parts  of  Mr.  Alexander's 
experimental  essays. 

Lewis,  1791,  advised  surgical  treatment 
of  goitre,  and  Doser  described  a  monstrous 
goitre  successfully  treated  by  operation. 

Iledenus,  1821,  suggested  surgical  treat- 
ment for  goitre. 

Speyer,  1832,  made  observations  on  the 
surgical  treatment  for  goitre,  and  Ileiden- 
reich,  1835,  made  some  experiments  on 
both  surgical  and  medicinal  treatment  for 
goitre. 

Hancke,  1838,  reported  his  observations 
on  the  surgical  treatment  for  goitre,  and 
Schindler,  1840,  described  the  methods  of 
surgical  treatment  for  goitre. 

Heidenreich,  1843,  reported  on  the 
pathology,  anatomy  and  surgery  of  the 
goitre;  Heidenreich,  1845,  on  surgery  of 
the  goitre,  and  Petit,  184S,  reported  a 
case  of  goitre  in  which  operation  resulted 
in  death. 

Porta,  1849  ;  Werner,  1853  ;  Hess,  1854  ; 
and  Kuchler,  1855,  made  reports  on  sur- 
gical treatment  for  goitre;  while  Rennes, 
1855,  operated  on  goitre  with  success. 

Mayorfils,    1856,    reported    a    case    of 


SURGERT  OF  THE   THTROID. 


goitre  where  operation  proved  success- 
ful. 

There  are  tabulated  statistics  of  the 
young  recruits  in  the  military  service  of 
Chalon,  1S59,  showing  that  those  who 
were  operafed  on  for  goitre  were  cured 
and  re-enlisted. 

Lebert,  1S62  ;  Steiger,  1862;  andMeeh, 
1S64,  operated  for  goitre. 

Hansen,  1864,  exposed  the  causes  which 
appear  to  determine  an  acute  goitre  found 
in  the  Fifth  Regiment  garrisoned  at  Col- 
mar. 

Konig,  1865,  reported  on  the  surgical 
treatment  of  goitre  for  asphyxia. 

Uhl,  1867;  Lucke,  1S6S;  Schwalbe, 
1872,  and  Sittel,  1872,  each  advocated 
surgical  treatment  for  goitre. 

Deininger,  1875;  Standenmayer  and 
Gay,  1876,  each  operated  for  goitre. 

Rose,  1878,  reported  a  carcinomatous 
goitre  treated  surgically,  and  Grundier, 
1883,  one  of  cachexia  in  a  simple  goitre 
treated  surgically. 

Harsant,  1888,  reported  cases  illustrating 
the  surgery  of  the  thyroid  gland. 

Roux,  1891,  reported  115  operations  on 
goitre,  and  Wette,  1892,  on  the  symptom- 
atology and  surgery  of  goitre. 

Xeudorfer,  1892,  reported  a  primary 
goitre  with  cachexia,  myxedema  of  the 
thyroid  gland  treated  by  operation,  and  a 
case  of  tetanus  operated  upon. 

Sulzer,  1893,  reported  200  operations 
for  goitre. 

Shepherd,  1895,  contributed  a  report  on 
the  surgical  treatment  of  certain  forms 
of  bronchocele,  with  reports  of  sixteen 
cases. 

Lugenbuhl,  1895,  had  a  case  of  con- 
genital goitre  treated  surgically. 

Talmon-Gros,  1S95,  reported  cachexia 
with  primary  goitre,  and  myxedema 
treated  surgically. 

Heydenreich,  1896,  reported  on  the 
treatment  of  retrosternal  goitre,  and  Ika- 
vitts,  1896,  on  the  etiology  of  goitre,  with 
review  of  sixteen  cases  of  its  surgical 
treatment. 

Sandelin,  1896,  reported  his  observa- 
tions on  goitre,  with  eighty  cases  operated 
upon. 

Ferguson,  1896,  reported  on  the  surgery 
of  the  thyroid  gland,  and  Ikehara  and 
Watsuzi,  1896,  on  its  surgical  treatment 
for  bronchocele. 

Marsil,  1896,  reported  on  the  surgical 
and    medical    treatment    for   goitre,    and 


Hitchcock,  1897,  reported  his  observation 
on  surgery  of  the  thyroid  gland  and  myx- 
edema. 

Austin,  1897,  considered  the  origin  of 
goitre,  with  remarks  on  its  treatment. 

Jonnesco,  1897,  made  a  total  resection 
of  the  cervical  sympathetic,  with  treat- 
ment for  exophthalmic  goitre  and  epilepsy. 

Hitchcock,  1897,  wrote  on  the  surgery 
of  the  thyroid  gland  and  myxedema,  while 
Wette,  1897,  reported  a  bronchocele  treated 
surgically. 

Vanderlinden,  1S97,  reported  a  case  of 
goitre  treated  surgically. 

Soupault,  1897,  made  experiments  on 
the  histology  and  surgical  treatment  of  the 
goitre. 

Peugniez,  1S98,  advocated  surgical  treat- 
ment for  goitre,  and  reports  a  case  of 
resection  (bilateral)  of  the  grand  cervical 
sympathetic. 

Wolfram,  1898,  reported  on  surgical 
intervention  for  goitre,  with  a  report  of 
ten  cases  treated  surgically. 

Hendley,  1899,  gave  notes  on  eleven 
cases  of  goitre  operated  upon,  and  Petroff, 
1899,  reported  thirty-six  cases  of  goitre 
treated  by  Kocher's  method. 

Katzenstein,  1899,  reported  on  degen- 
eration of  the  thyroid  gland,  with  remarks 
on  surgical  treatment  for  goitre,  and 
Preindlsberger,  1900,  on  the  operative 
treatment  for  dislocation  of  goitre. 

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204 


SURGERY  OF  THE   THYROID. 


Preindisberger.  Wolfler,  Wien.  klin.  woch. 
1900,  xlii,  523. 

Brunner.  Beitr.  z.  klin.  chir.,  Tubing,,  1900, 
xxvi,  233  259. 

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II  fiuf. 

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541-549- 

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xxiv,  288305. 

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1902,  p.  6m  622. 

TUVROIDOTOMV     (1S16-I9O4). 

In  this  class  are  included  all  punctures 
and  incisions  -of  any  character  in  the 
normal  or  pathologic  thyroid  for  any 
purpose. 

Tapping  is  only  applicable  in  cystic 
goitre,  and  there  only  successful  when  the 
fluid  is  uf  a  watery  c!i  iractt- r.  The  deiiber 
fluids  will  not  flow  through  a  trocar.  If 
a  cyst  contains  blood  it  will  re-fiil,  and 
then  the  condition  is  more  serious  than 
before.  Injections,  cautery,  seton,  together 
with  division  of  the  isthmus,  are  consid- 
ered in  their  respective  chapters. 

Historical.  —  Newhan,  1816,  reported 
two  cases  successfully  treated  by  thyroid- 
otomy,  and  Von  Walther,  1S21,  made  a 
thyroidotomy  for  aneurism. 

Lemaire,  182 1,  made  observations  on 
incision  for  cystic  goitre. 

Kennedy,  1S23,  made  disquisilive  re- 
marks on  certain  modes  of  treating  bron- 
chocele,  with  cases  and  dissections. 

Selwyn,  1838,  reported  on  encysted 
dropsy  of  the  thyroid  gland,  with  a 
method  of  operation  and  cure  and  cases 
treated  successfully  at  the  Ledbury  Dis- 
pensary. 

Blumhardt,  1S52,  made  an  incision  for 
cystic  goitre,  and  Betz,  1853,  operated 
upon  one  of  the  same  character. 

Iley,  1858,  operated  for  bronchocele, 
and  Cussack,  1857,  had  a  case  of  dyspnea 
from  bronchocele  relieved  by  division  of 
the  cervical  fascia. 

Ferguson,  18,9,  reported  a  case  of  seri- 
ous bronchocele  treated  by  puncture. 

Ancelon,  1863,  Schaetzke,  1864,  and 
Bovet,  1864,  each  contributed  their  obser- 
vations on  surgical  treatment  for  cystic 
goitre ;  and,  furthermore,  made  observa- 
tions on  the  transformation  of  parachy- 
matous  goitre  by  tearing  subcutaneously. 

Greene,  1866,  successfully  removed  a 
large  bronchocele ;  wound  of  internal 
jugular  vein ;  ligature. 


Warren,  1867,  reported  a  large  encysted 
thyroid  tumor  removed  by  incision ;  re- 
covery. 

Patrubau,  1867;  Hamburger,  1867,  and 
Weinlechner,  1870,  each  operated  on  cys- 
tic goitre,  while  in  another  case  of  paren- 
chymatous goitre  caus'ics  were  injected. 

Blackman,  1870,  reported  pendulous 
pedunculated  bronchocele  successfully  re- 
moved. 

Richet,  1873,  punctured  and  drained  a 
cystic  goitre,  thereby  inflicting  and  causing 
abscess  of  spleen. 

Macaro,  1873,  punctured  a  multilocular 
cyst,  destoying  the  pouch  ;   recovery. 

Holmes,  1873,  reported  a  case  in  which 
a  large  bronchocele  was  removed  with 
fatal  result. 

Gibb,  1876,  and  Hamilton,  1876,  each 
made  a  division  of  the  isthmus  of  the 
thyroid  gland  to  relieve  dyspnea  in  bron- 
chocele. 

Nelson,  1S76,  reported  fibro-cystic  bron- 
chocele ;   operation  and  recovery. 

Bairardi,  1878,  aspirated  a  voluminous 
goitre. 

Gacon,  1878,  contributed  a  study  on  the 
treatments  of  cystic  goitre. 

Von  MosetigMoorhof,  1878  and  1879, 
made  thyroidotomies, 

Duplay,  1878,  reported  a  simple  punc- 
ture for  large  cystic  goitre. 

Maclean,  1879,  had  a  case  of  cystic 
goitre  complicated  by  epilepsy  operated 
with  complete  and  permanent  cure  of  the 
epilepsy. 

Smith,  1882,  reported  a  case  of  cystic 
bronchocele;  impending  asphyxia;  aspi- 
ration, relief;  early  re  enlargement ;  at- 
tempt at  radical  cure;  traumatic  fever; 
death. 

Bellamy,  1883,  contributed  a  note  on 
the  treatment  of  a  case  of  fibro-cystic 
bronchocele. 

Robson,  1887,  reported  a  method  of 
treating  thyroid  cysts;  illustrating  cases. 

Vascheli,  1887,  reported  a  case  of  cystic 
goitre  treated  by  "shelling  out." 

Butaresco.  1889,  had  a  case  of  suffoca- 
tive goitre  successfully  treated  by  opera- 
tion. 

Alibert,  1894,  treated  a  cystic  goitre 
surgically  by  thyroidotomy. 

Bowlby,  1S94,  reported  a  case  of  large 
intrathoracic  cystic  goitre  causing  dyspnea 
and  treated  by  operation. 

IMarsh,  1894,  reported  on  the  treatment 
of  bronchocele,  with  notes  of  five  cases 


SURGERr  OF  THE   THYROID. 


205 


of  the  parenchymatous  form  operated 
upon  for  urgent  pressure  symptoms. 

Carless,  1894,  operated  for  cystic  tumor 
of  thyroid ;   death  from  sudden  dyspnea. 

Morris,  1895,  reported  two  cases  of 
operation  for  cystic  bronchocele. 

Williams,  1896,  reported  a  thyroid  cyst 
in  a  child  eleven  months  old  ;  operation  ; 
recovery. 

De  Santi,  1899,  reported  on  exploration 
of  the  thyroid  for  dyspnea. 

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197-200. 


306 


SURGERY  OF  THE   THYROID. 


Marsh.  Birmingham  Med.  Review,  1894,  xxvi, 
271-277. 

Alibert.     Bordeaux,  1894. 

Lordi.     Ufficiale,  Napoli,   1894,  '''^'>  465- 

Carless.  Kings  Coll.  Hosp.  Rep.,  1894-5, 
London,  1896,  ii,  142. 

Morris.     Lancet,  London,  1895,  '>  28  30. 

British  Med.  Journal,  London,  1895,  ">  9°'  6. 

Grant.     Anti  Med.  Journal,  1896,  xi,  157-162. 

Williams.  British  Med.  Journal,  London, 
1896,  i,  970. 

Ana.  Surg.,  Philadelphia,  1899,  xxx,  564,  570, 
3  pi. 

De  Santi.  Med.  Press  and  Circular,  London, 
1899,  Ixvii,  248. 

Massa.  Gior.  med.  d.  r.  esercito,  Roma,  1900, 
xlviii,  126. 

SETON  (1819-I904). 

Seton  was  first  employed  by  Moreau, 
more  epecially  in  the  cystic  form  of  goitre. 
Many  such  cases  have  been  cured  in  this 
way  occupying  more  or  less  time  for  its 
accomplishment.  The  Feton  should  not 
be  introduced  into  a  sac  containing  blood. 
In  these  days  of  more  advanced  surgery 
the  seton  is  not  employed. 

Historical. — Quadri,  18 19,  reported  a 
new  method  for  treating  bronchocele  by 
seton,  and  Hutchinson,  1821,  reported 
several  cases  of  bronchocele  treated  by 
seton. 

Lyford,  1827,  had  a  case  of  goitre  suc- 
cessfully treated  by  seton,  and  Kennedy, 
1847,  a  case  of  enlargement  of  the  thyroid 
gland  treated  by  seton. 

Hugier,  1854,  treated  a  voluminous 
goitre  by  seton,  while  Appley,  1874,  cured 
a  case  of  cystic  goitre  by  seton. 

Molliere,  1880,  employed  seton  in  a 
large  cystic  goitre. 

Jowers,  1882,  had  a  case  of  cystic  bron- 
chocele cured  by  seton. 

Barling,  1890,  recorded  a  case  of  sup- 
puration in  the  thyroid  gland;  drainage; 
recovery. 

Smith  reported  two  cases  of  broncho- 
cele successfully  treated  by  the  seton. 

BIHLIOGRAPHY. 

Qijadri.  Med.-Chir.  Tr.,  London,  1819,  x, 
1626. 

Hutchinson.  Med.-Chir.  Tr.,  London,  1821, 
xi,  235  257. 

Lyford.  Med.-Chir.  Tr.,  London,  1827,  vii, 
263. 

Kennedy.  Dublin  Qiiarterly  Journal  Med. 
Science,  1847,  iii,  270. 

Huginer.     Bull.  soc.  de  chir.,  Paris,  1854-5,  v, 

113. 

Appley.  Med.  and  Surg.  Reporter,  Philadel- 
phia, 1874,  xxx,  521. 

Molliere.  Mem.  et  compt.  rend.  soc.  d.  sc. 
med.  de  Lyon  (1879),  i88o,  xix,  pt.  2,  208. 


BadoUe.  Mem.  et  compt.  rend.  soc.  d.  sc. 
med.  de  Lyon  (1880),  i88r,  xx,  pt.  2,  207. 

Jowers.     London  Lancet,  1882,  ii,  488. 

Smith.     London  Lancet,  1884,  i,  12. 

Despres.     Gaz   d.  hop.,  Paris,  1885,  Iviii,  523. 

Barling.  Birmingham  Med.  Review,  1890, 
xxviii,  151. 

INJECTIONS    (174O-I904). 

Many  substances  in  the  form  of  solu- 
tions have  been  injected  into  both  solid 
and  cystic  growths  of  the  thyroid  gland. 

Iodine,  zinc  chloride,  iodoform,  alcohol, 
ergotine  and  argenti-nitras  are  among  the 
more  common  employed. 

Iodine  injections  are  indicated  in  the 
hypertrophic  follicular  and  recently  devel- 
oped goitres.  Such  subjects  are  especially 
susceptible  to  iodine  only.  Zinc,  iodo- 
form, alcohol  and  other  astringents  are 
indicated  in  the  soft  goitre,  especially  those 
of  rapid  development. 

Bacellis  suggested  a  treatment  for  echi- 
nococcus,  the  principle  of  which  has  been 
adopted  many  times  during  the  last  cen- 
tury. After  removing  but  a  small  amount 
of  the  fluid  a  similar  amount  of  solution 
of  mercuric  chloride,  i  ;  1,000,  is  intro- 
duced. Hemorrhage  is  thereby  avoided 
as  sufficient  pressure  is  maintained.  The 
parasite  dies  and  the  contents  of  the  sac 
are  absorbed.  He  and  Pirrone  recom- 
mend this  procedure  in  hydatid  cysts  of 
the  liver,  several  cases  of  which  they  report 
having  been  successfully  treated  this  way. 

This  treatment  cannot  be  advised  in 
hydatids  of  the  thyroid  gland.  On  the 
contrary  it  would  seem  irrational  to  apply 
it  to  any  organ,  gland  or  part  of  the  hu- 
man economy,  for  there  are  other  methods 
more  rapid  and  radical.  Then,  too,  there 
is  less  danger  from  infection  and  injury  to 
blood-vessels.  The  introduction  of  a  needle, 
while  less  dangerous  than  chemicals,  into 
living  organs,  is  not  without  more  ar  less 
anxiety. 

The  special  reason  for  applying  this 
method  would  seem  that  it  prevents  hem- 
orrhage. This  cannot  be  accepted,  as 
there  are  other  methods  such  as  packing 
with  gauze,  hot  water  irrigation  and  the 
application  of  forceps  and  ligatures  that 
are  more  effectual.  Therefore,  the  injec- 
tive  treatment  for  hydatid  or  any  other 
kind  of  cyst  in  the  thyroid  or  elsewhere 
should  be  condemned. 

Historical. — Liuth,i740;  Bowie,  1830; 
Barker,  1834;  Ileidenreich,  1848;  Hilton, 
1852;     Jobert    de    Lamballe,    1853;     and 


SURGER7'  OF  THE   THYROID. 


207 


Guntner,  1859,  each  report  a  cystic  goitre 
treated  by  injection  of  iodine. 

Dufour,  1S60,  punctured  thyroid  abscess, 
and  injected  iodine,  with  partial  recovery. 

Senftlebon,  i860,  employed  iodine  in- 
jections for  cure  of  cystic  goitre. 

Bryant,  1861,  reported  a  cure  of  cyst 
in  the  thyroid  gland  by  injection  of  iodine. 

Boucaud,  1862,  cured  a  goitre  by  inject- 
ing iodine. 

Savory,  1867,  reports  a  large  cyst  of  the 
thyroid  gland  successfully  treated  by  in- 
jection of  iodine. 

Heller,  1868,  injected,  subcutaneously, 
tincture    of    iodine    for  enlarged    thyroid 

Mears,  1873,  treated  cystic  goitre  by 
evacuation  and  injection  of  the  solution 
of  the  perchloride  of  iron. 

Gosselin,  1874,  treated  a  cystic  goitre 
by  injection  of  iodine. 

Erichsen,  1875,  tapped  a  cystic  goitre 
and  injected  with  iodine,  greatly  relieving 
patient. 

Lupo,  1877,  reported  a  cystic  goitre 
treated  by  iodine  injection. 

Koch,  1877,  reported  a  case  of  cystic 
goitre  treated  by  injection  of  iodine,  re- 
sulting in  gangrene;   death. 

Coghill,  1877.  reported  on  the  hypo- 
dermic treatment  of  bronchocele  by  ergo- 
tine. 

Palmer,  1878,  reported  goitre  success- 
fully treated  by  intraglandular  injections 
of  ergot. 

Burton,  1878,  tapped  a  cystic  goitre, 
injected  with  iodine  and  iron  ;  suppura- 
tion ;  cured. 

Reynier,  1879,  reported  on  hypertrophy 
of  the  thyroid  gland  treated  by  injection 
of  iodine. 

Gosselin,  1879,  treated  goitre  by  suffo- 
cation and  injection  of  iodine. 

Folier,  18S0,  successfully  treated  goitre 
by  injection  of  acohol. 

Grunmach,  1882,  treated  goitre  by  in- 
jection of  arsenic. 

Dumont,  1884,  reported  a  case  of  goitre 
treated  by  injection  of  arsenic. 

Cameron,  1884,  treated  goitre  success- 
fully by  injection  of  hydrochloric  acid. 

Beau,  1884,  reported  on  iodoform  in  the 
treatment  of  goitre. 

Szuman,  1884,  advocated  iodine  injec- 
tiction  for  cystic  goitre. 

Krieg,  1884,  treated  goitre  by  injection 
of  iodine,  and  McCaskey,  1885,  treated  a 
goitre  successfully  with  iodine  internally 
and  by  injection. 


Haven,  1886,  successfully  treated  goitre 
by  carbolic  acid. 

Terrillon  and  Sebileau,  1887,  report  a 
case  of  goitre  treated  by  injection  of 
iodine. 

Puech,  1888,  contributed  a  study  on  the 
treatment  of  goitre  by  injection  of  iodine. 

Terrillon,  1889,  treated  the  goitre  by 
injection  of  iodine. 

Dionis  des  Carrieres,  1889,  successfully 
treated  goitre  by  injection  of  iodine. 

O'Reilly,  1892,  treated  goitre  by  iodine, 
mercury  and  potash  injections. 

Marquet,  1894,  injected  iodoform  for 
goitre. 

Ballet  and  Euriquez,  1894,  experimented 
by  injecting  subcutaneously  thyroid  extract 
for  goitre. 

Sene,  1895,  cured  goitre  by  injection  of 
thyroid  gland. 

Gottrelle,  1896,  injected  thyroid  extract 
for  treatment  of  goitre. 

Ghosal,  1897,  reported  on  the  use  of 
dilute  hydrochloric  acid  in  cystic  goitre, 
with  notes  of  a  case  successfully  treated 
with  that  drug. 

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Chosal.   Indian  Lancet,  Calcutta,  1897,  i''^>  ^26. 

Rosenberg.  Berlin  klin.  woch.,  1897,  xxxiv, 
8046. 

ALCOHOL. 

Folier.  Bull.  d.  sc.  med.  di  Bologna,  1880, 
vi,  377  383- 

ERGOTINK. 

Coghill.     Lancet,  London,  1877,  ii,  158. 

Palmer.  Tr.  Am.  Med.  Association,  Philadel- 
phia, 1878,  xxix,  155-160. 

Fox.  New  England  Med.  Monthly,  Bridge- 
port, Conn.,.  1885-6,  V,  496. 


Grunmach.     Berlin     klin.     woch.,    1882,     xix, 

493  5- 

Dumont.     Cor.-bl.    f.    schweiz    aerzte,    Basel, 
1884,  xiv,  201-208. 

HYDROCHLORIC    ACID. 

Cameron.  Liverpool  Med.  Chir.  Journal,  1884, 
iv,  417-20. 

Ghosal.     1897. 

PKRCHLORIDE    OF    IRON. 


Mears,     Philadelphia  Med.  Times,  1873-4,  iv» 


741. 


IODOFORM. 


Beau.  Northwest.  Lancet,  St.  Paul,  18845, 
iv,  121. 

Marquet.  Limousin  med.,  Limoges,  1894, 
xviii,  74. 

Rev.  internat.  de  rhinol.,  otol.  et  laryngol., 
Paris,  1894,  'v>  181-183. 

CARBOLIC    ACID. 

Haven.  Weekly  Med.  Rev.,  St.  Louis,  1886, 
xiv,  288. 

EXTRACT    THYROID. 

Ballet  and  Euriquez.  Bull,  et  mem.  soc.  med. 
d.  hop.,  Paris,  1884,  ^i,  805. 

Sene.  Jour,  de  med.  et  chir.  prat.,  Paris,  1895, 
Ixxi,  369  374. 

Cottrelle.  Gaz.  med.  de  Picardie,  Amiens, 
1896,  xiv,  60-65. 


SURGERT  OF  THE   TIITROID. 


209 


CAUTERY     (185O-I9O4). 

Cautery^  both  thermic  and  chemical, 
has  been  employed  in  the  treatment  of 
diseases  of  the  thyroid  gland  with  more 
or  less  benefit.  A  hot  iron  varying  in 
degree  of  heat  produced  by  electricity  or 
otherwise  has  been  applied  with  very 
gratifying  results  in  a  few  cases.  They 
have  been  abandoned  because  of  their 
danger  and  uncertainty  as  to  beneficial 
results. 

Caustics  were  used  by  Celsus,  who  first 
suggested  them.  They  may  be  introduced 
into  a  solid  or  cystic  tumor  after  an  in- 
cision has  been  made  through  the  cuta- 
neous structure,  or  they  may  be  plunged 
into  the  tumor  or  cyst  through  the  skin  in 
the  form  of  dagger-like  crystals  or  solution 
with  a  needle. 

Historical. — Bonnet,  1850,  reported  a 
goitre  entering  between  the  sternum  and 
trachea.  The  cautery  was  used  with  ap- 
parent success;  while  Larghi,  1873-1874, 
employed  cautery  in  the  treatment  of 
goitre. 

BIBLIOGRAPHY. 

Bonnet.     Gaz.  med.  de  Ljon,  1850,  ii,  79  82. 

Larghi.  Gur.  d.  r.  acad.  med.  chir.  di  Lorino, 
1856,  XXV,  3  10. 

Gaz.  d.  hop.,  Paris,  1868,  xlv,  177. 

Dumolard.     Montpelier,  1868. 

Larghi.  Ann.  univ.  di  med.,  Milano,  1873, 
ccxxvii,  260,  I  pi.;  512,  i  pi.  ;  1874,  ccxxviii,  183. 

DIVISION    AND    RESECTION    OF     ISTHMUS 
(1874-I904). 

Operations  upon  the  isthmus  of  the 
thyroid  gland  have  been  frequently  made, 
especially  in  England. 

Historical. — Holthouse,  1874,  was  the 
first  to  resect  the  isthmus,  while  Gibbs, 
1876,  was  the  first  to  simply  divide  the 
isthmus. 

Tillaux,  1883,  and  Jams,  1884,  were 
its  special  advocates.  Twenty  resections 
were  tabulated,  with  four  deaths,  one  of 
which  occurred  at  the  time  of  operation. 

Morton,  1896,  made  the  operation,  and 
Gibbs  made  two  such  operations. 

It  was  claimed  that  relief  from  dyspnea 
and  lessening  of  the  size  of  the  growth 
resulted. 

The  operations  were  based  upon  the 
thought  that  the  isthmus  constricted  the 
trachea,  but  this  teaching  was  fallacious, 
as  it  was  found  that  the  pressure  was 
lateral  and  not  antero-posterior. 

Berry  offers  the  most  plausible  explana- 


tion for  the  relief  obtained  by  division  or 
resection  of  the  isthmus  when  he  says  that 
it  is  due  to  "shrinking  of  the  lateral 
lobes." 

This  operation  should  not  be  advised, 
now  that  safer,  more  radical  and  effica- 
cious methods  have  been  determined. 

THYROIDECTOMY    (1778-1904). 

Thyroidectomy  may  be  partial  or  com- 
plete removal  of  the  thyroid  tissue,  whether 
in  the  form  of  one  or  more  lobes.  How- 
ever, complete  removal  should  not  be  done, 
except  when  the  neoplasm  is  malignant. 
It  is,  indeed,  seldom  that  the  thyroid 
tissue  is  completely  removed  in  any  opera- 
tion, and  for  that  reason  the  term  thyroid- 
ectomy has  been  erroneously  applied  to 
operations  involving  but  partial  removal. 
Partial  thyroidectomy  should,  therefore, 
be  the  term  applied. 

Technique.  —  All  aseptic  precautions 
having  been  instituted,  a  transverse  in- 
cision is  made  through  the  cutaneous 
structures  immediately  over  the  clavicle 
on  the  side  corresponding  with  the  gland 
to  be  attacked.  The  superficial  fascia  and 
platysma  myoides  is  divided  from  below 
upwards,  and  retracted  laterally  while  the 
skin  is  retracted  upwards.  The  gland, 
once  approached,  may  be  dissected  from 
its  surrounding  tissues  with  the  finger; 
but  little,  if  any,  hemorrhage  will  have 
taken  place  during  this  entire  procedure. 

The  gland  is  at  once  delivered  exter- 
nally, and  its  vessels  transfixed  and  ligated 
separately  with,  preferably,  kangaroo  ten- 
don, great  care  being  taken  not  to  injure 
the  recurrent  laryngeal  nerves.  All  ves- 
sels once  severed,  the  wound  may  be  dried 
with  gauze,  the  immediate  overlying  tis- 
sues sutured  with  absorbable  material,  and 
the  cutaneous  structure  with  silkworm- 
gut.  Drainage  is  not  always  necessary, 
but  when  so  it  should  be  done  with  a 
small  piece  of  gauze.  Dry  sterile  gauze 
is  all  that  is  further  required. 

The  general  mortality  of  this  operation 
is  7  per  cent.  (Booth),  while  the  percent- 
age of  death  in  cases  of  exophthalmic 
goitre  is  much  higher.  Rehn,  of  Frank- 
fort, who  collected  177  cases,  places  it  at 
13.6  per  cent.  His  figures  practically  agree 
with  the  experience  of  Kocher,  who  lost 
two  of  fifteen  cases.  Jonnesco  agrees 
with  Starr  that  the  mortality  is  over  17 
per  cent.,  and  rejects  the  operation  be- 
cause of  the  high  death-rate. 


310 


SURGBRT  OF  THE   THYROID. 


When  we  remember  that  many  of  the 
unsuccessful  cases  have  not  been  reported, 
it  seems  reasonable  to  place  the  mortality 
of  thyroidectomy  for  exophthalmic  goitre 
at  20  per  cent.  Rehn  claims  57.6  per 
cent,  of  cases  for  thyroidectomy.  Jon- 
nesco  claims  that  the  reported  successes  of 
this  operation  have  been  largely  among 
those  atypical  cases  in  which  the  goitre 
long  preceded  the  ocular  and  cardiac  symp- 
toms. Doyon  is  a  strong  advocate  of  thy- 
roidectomy, and  would  resect  the  sympa- 
thetic only  after  failure  of  the  former 
operation. 

Reverdine  reports  42  cases  of  partial 
extirpation  resulting  in  death  as  follows  : 
Suffocation  i,  pneumonia  and  bronchitis 
18,  syncope  2,  lesions  of  recurrent  nerve 
I,  collapse  I,  tetany  i,  myxedema  and 
tetany  i,  hemorrhage  6,  septicemia  7,me- 
diastinitis  i,  various  and  unknown  3.  He 
also  records  10  cases  of  complete  extirpa- 
tion, 4  from  suffocation,  3  from  pneu- 
monia and  bronchitis,  and  3  unknown. 

Iricomini,  72  cases,  places  the  mortality 
at  15  per  cent.,  and  Sorgo,  172  cases  at 
14  per  cent. 

Liebrecht  reports  the  following  table  : 


Cases.  Recov-  Death.    Mortal- 
eries.  ity. 


Before  1851...     5^.        35         17         31.48  per  cent. 

1851-1876 138       loi         27         20  30       " 

1877-1882 164       140         24         14  63       " 

Reverdine,  up  to  1898,  reports  6,103 
cases  with  5,927  recoveries  and  176  deaths, 
a  mortality  of  2.88  per  cent. 

Berry  reports  100  cases  with  only  i 
death  (1S94-1901). 

Delore  [Revue  de  Chirurgie,  June  10, 
1903)  reports  a  case  of  fibroma  of  the  thy- 
roid, which  is  exceedingly  rare.  It  was 
single  and  identical  with  uterine  fibroma. 
They  may  be  encapsuled  or  diffused,  and 
correspondingly  easy  or  difficult  to  remove. 
Removal;  hemorrhage  slight.  Myxedema 
has  never  been  observed  as  result.  Dif- 
fused form  difficult  and  prognosis  bad. 

Complications    During    Operations. — 

1 .  Sudden  death  from  anesthetic,  shock, 
hemorrhage  or  injury  to  nerves. 

2.  Injury  to  nerves,  such  as  the  recur- 
rent laryngeal,  sympathetic,  vagus,  and 
hypoglossal. 

3.  Injury  to  trachea,  pleura,  pharynx  or 
esophagus. 

4.  Secondary  complications  ;  secondary 
hemorrhage  ;  recurrent  hemorrhage  ;  sep- 


sis; scar  compressing  on  the  recurrent 
nerves  and  tetany. 

Personal  Operations. — No.  i.  Male, 
twenty  seven  years,  white,  parenchy- 
matous goitre,  right  side.  Eight  years' 
duration,  associated  with  epilepsy.  Re- 
moved five  and  one-half  ounces,  leaving 
small  amount  of  the  base;  recovery. 

No.  2.  Female,  forty-five  years, white, 
cyst  right  side,  size  of  goose-egg,  for  sev- 
eral years.  Removed  all  but  small  portion 
of  right  gland  ;   recovery. 

No.  3.  Female,  white,  twenty  eight 
years,  parenchymatous  goitre,  right  side, 
for  seven  years.  Removed  four  and  one- 
half  ounces,  leaving  but  little  glandular 
tissue  ;    recovery. 

No.  4.  Female,  twenty-two  years, 
white,  right  side,  parenchymatous  exoph- 
thalmic goitre,  several  years'  duration. 
Tachycardia.  Removal,  1897,  leaving 
small  portion  of  gland.  Recovery.  In 
1903  stump  grew  size  of  hen  egg  and 
symptoms  returned.  Removal  complete, 
small  left  gland  undisturbed.     Recovery. 

No.  5.  Male,  thirty  years,  white,  cys- 
tic goitre  three  years,  left  side  behind 
manubrium  of  the  sternum.  Severe  pres- 
sure upon  trachea.  Immediate  operation 
imperative  ;  removal  of  six  ounces  of  fluid, 
sac  and  nearly  all  of  left  lobe;  right  lobe 
undisturbed;   recovery. 

No.  6,  Female,  twenty-seven  years, 
white,  exophthalmic  parenchymatous 
goitre,  left  side,  seven  years.  Tachycar- 
dia pronounced ;  removed  four  ounces 
parenchymatous  tissue,  leaving  but  a  small 
portion  of  the  left  gland.  There  was  a 
normal  gland  upon  the  right  side;  re- 
covery. 

No.  7.  Female,  twenty- seven  years, 
white,  exophthalmic  goitre,  left  side,  for 
several  years.  November,  1902  (two  cysts 
each  size  of  guinea  egg),  removed.  This 
was  the  most  severe  case  of  exophthalmos 
of  all  operated  upon  ;  recovery  and  great 
improvement. 

No.  8.  Female,  fourteen  years,  white, 
parenchymatous  goitre,  right  side,  three 
years'  duration.  Removed  three  and  one- 
half  ounces  glandular  tissue;  recovery. 
Improvement  slight;  continue  to  have 
severe  nervous  symptoms,  November, 
1902. 

No.  9.  Female,  forty-five  years,  white, 
married,  seven  children,  exophthalmic 
goitre  for  twenty  years  ;  severe  tachycardia 
and  nervousness.     Removed  six  ounces  of 


SURGERr  OF  THE  THYROID. 


azi 


parenchymatous  tissue  from  right  lobe ; 
one  four-ounce  cyst  (left  subclavicular) 
and  two  small  cysts  on  left  side  ;  recovery 
most  rapid,  with  complete  cure,  May, 
1904. 

No.  10.  Female,  twenty-seven  years, 
white,  married,  one  child  four  years  old. 
Parenchymatous  goitre,  right  side,  four 
years'  duration.  No  tachycardia  or  ex- 
ophthalmos. Pressure  symptoms  aggra- 
vated ;  chloroform ;  removed  five  ounces 
of  glandular  tissue,  leaving  a  small  por- 
tion, as  no  other  thyroid  tissue  could  be 
found.  Recovery  uneventful,  September, 
1903. 

Summary:  10  subjects;  8  females;  2 
males  ;  10  recoveries  ;  5  parenchymatous  ; 
4  exophthalmic;  2  cysts;  3  solid  and 
cystic;  7  single;  3  multiple;  6  right  side, 
3  left  side;    i  both  sides. 

Eruptio7i  Appearing  Upoti  the  Skin 
Follo'iL'iiig  Thvroidecto7ny. — A  discrete 
eruption  has  appeared  within  thirty  hours 
after  the  removal  of  the  thyroid  cysts  in 
two  cases.  It  first  appears  as  a  macule, 
papule  or  vesicle,  and  then  a  pustule, 
greatly  resembling  the  eruption  of  variola 
even  in  the  process  of  desquamation.  The 
duration  of  either  stage  is  not  so  long  as 
variola.  Desquamation  is  complete  by 
the  end  of  the  sixth  day,  leaving  a  highly 
reddened  circular  area  about  one-half  the 
size  of  an  ordinary  pea,  which  gradually 
disappears,  leaving  no  cicatrix.  This 
eruption  is  in  all  probability  due  to  thy- 
roidine  which  escaped  from  the  denuded 
stump  of  the  thyroid  gland.  I  have  not 
seen  any  mention  of  this  eruption,  which 
does  not  itch  or  cause  pain. 

Historical. — Freytag,  1778,  made  an 
extirpation  for  enlarged  thyroid  gland. 

Giraud,  1792,  contributed  his  obser- 
vations on  the  extirpation  of  a  part  of  the 
thyroid  gland. 

Tlie  Lancet.,  of  London,  1823,  reports 
an  operation  for  the  removal  of  a  very 
large  bronchocele. 

Zartmann  made  an  extirpation  of  the 
thyroid  gland. 

Green,  1829,  removed  the  right  lobe  of 
the  thyroid  gland. 

Liston,  1830,  removed  enlargement  of 
the  isthmus  of  the  thyroid  gland. 

Dupuytren,  1830,  reported  a  fibro-cell- 
ular  tumor  of  the  left  lobe  of  the  thyroid 
gland  in  an  infant.  An  extirpation  was 
made,  ligating  the  pedicle,  patient  dying 
eighteen  hours  after  operation. 


Mandt,  1832  ;  Smith  1835  ;  and  Roux, 
1836,  each  reported  a  case  of  extirpation 
for  goitre. 

Voisin,  1836,  reports  ablation  of  a 
tumor  situated  in  the  region  of  the  thy- 
roid gland ;   recovery. 

Wilson,  1837,  described  cases  of  re- 
moval of  part  of  the  thyroid  gland. 

Karawajew,  1843,  made  a  partial  extir- 
pation for  goitre. 

Hoyt,  1847,  reported  the  successful  ex- 
tirpation of  the  thyroid  gland. 

Otis,  1854,  reported  a  case  in  which  an 
enlargement  of  the  isthmus  of  the  thyroid 
body  was  successfully  extirpated. 

Douglas,  1856,  made  observations  on 
extirpation  of  the  cystic  goitre  resulting 
in  cure. 

Cooper,  i860,  reported  an  operation  for 
the  removal  of  bronchocele  ;  death  of  pa- 
tient. 

Chassaignac,  1861,  made  a  complete 
ablation  of  the  thyroid  gland  by  the 
method  of  linear  destruction. 

Floeret,  1S61,  reported  an  ablation  of  a 
thyroid  cyst  with  the  assistance  of  the 
cautery. 

Parsons,  1862,  removed  an  osseous 
tumor  from  the  thyroid  gland. 

Voss  reports  a  successful  removal  of  the 
thyroid  gland. 

King,  1865,  recorded  cases  of  broncho- 
cele of  the  isthmus  of  the  thyroid  body, 
with  remarks  on  the  practicability  of  ex- 
cision under  certain  circumstances. 

Hamilton,  1865,  advocated  extirpation 
of  the  thyroid  body. 

M.  J.  B.  A.,  1866,  reported  on  the 
treatment  of  the  goitre,  with  the  effects 
of  thyroidectomy  and  injections. 

Bloxam,  1866,  reported  two  cases  of 
goitre;  removal  of  gland;  recovery. 

Sick,  1867,  made  a  total  extirpation  for 
goitre. 

Pesme,  1867,  reported  extirpation  for 
goitre.  Marshall  and  Von  Rozycki,  1868, 
each  made  an  extirpation  of  the  thyroid 
gland. 

Maury,  1871,  performed  an  extirpation 
of  the  thyroid  gland  for  cystic  enlarge- 
ment. 

Poland,  1871,  reported  a  tumor  of  the 
neck  in  connection  with  the  thyroid 
gland;  removal;  structure  thyroideal  ;  re- 
covery. 

Briere,  1871,  reported  on  treitment  of 
parenchymatous  goitre  by  extirpation. 

Watson,  1873,  made  an  excision  of  the 


SURGERr  OF  THE   THYROID. 


thyroid  gland,  and  Hodder,  1872,  re- 
ported fibro-cystic  disease  of  the  right 
half  of  the  thyroid  gland  and  its  removal. 

Hopmann  advocates  extirpation  for 
goitre,  and  Holmes,  1873,  had  a  case  in 
which  a  large  bronchocele  was  removed 
with  fatal  result. 

Durham,  1873,  removed  a  bronchocele, 
and  Michel,  1S73,  advised  complete  extir- 
pation of  the  thyroid  gland  in  cases  of 
suffocative  [cystic  and  parenchymatous 
goitre. 

Jessop,  1873,  extirpated  a  cystic  enlarge- 
ment of  the  thyroid  gland;  recovery. 

Fenwick,  1873,  reported  a  case  of  fibro- 
cystic bronchocele,  with  removal  of  the 
right  half  of  the  thyroid  body. 

Kocher,  1874,  made  an  extirpation  of 
the  thyroid  gland  ;  he  also  advocates  injec- 
tions fur  parenchytnutous  goiire. 

Skilosovski,  1S74,  and  Bruberger,  1876, 
each  made  a  total  extirpation  of  the  thy- 
roid gland. 

Menzel,  1876,  and  Miner,  1876,  each 
expatiated  on  the  feasibility  of  extirpating 
the  thyroid  gland  in  some  ca^es  of  disease, 
with  report  of  a  case. 

Homans,  1876,  made  an  excision  of  a 
cystic  adenoma  of  the  thyroid,  resulting  in 
a  cure. 

Willoughby,  1876,  reported  removal  of 
the  right  thyroid  gland. 

Spence,  1877;  Czerny,  1877;  and 
Albert,  1877,  each  removed  a  thyroid 
gland  for  goitre. 

Wood,  1877.  exhibited  a  specimen  of 
cystic  tumor  of  the  thyroid  gland  success- 
fully removed  from  the  living  subject. 

McLean,  1877,  reported  a  case  of  fibro- 
cystic tumor  of  the  thyroid  gland ;  ex- 
cision ;  recovery. 

Fuller,  1878,  successfully  removed  the 
right  lobe  of  the  thyroid  gland. 

Bottini  made  a  total  extirpation  for  a 
parenchymatous  goitre. 

McLean,  1S78,  reported  two  successful 
cases  of  extirpation  of  the  thyroid  gland 
for  fibro  cystic  tumor. 

Dowson,  187S,  had  a  case  of  hyper- 
trophy of  the  thyroid  gland,  successfully 
removing  the  right  lobe. 

Sands,  1878,  removed  a  congenital 
cystic  tumor  of  the  thyroid. 

Wolfler,  1878;  Boeckel,  1879;  and  Al- 
bert, 1879,  each  made  an  extirpation  of 
the  thyroid. 

Pean,  1879,  reported  on  surgical  treat- 
ment for  tumors  of  the  thyroid  gland. 


Tillaux,  1880,  made  a  thyroidectomy 
for  exophthalmic  goitre. 

Brochin,  1880,  made  an  ablation  for 
goitre  complicated  by  abscess  and  hemor- 
rhage;  death. 

Boursier,  1880,  reported  on  surgical 
intervention  for  tumor  of  the  thyroid 
gland. 

Boeckel,  1880,  made  an  excision  for 
suffocative  goitre. 

Bruno,  1S80,  and  Hermann,  1881,  each 
made  a  total  extirpation  for  goitre. 

Boeckel,  1881,  reported  a  thyroidectomy 
for  suffocative  goitre. 

Schlapuer,  1881,  made  a  total  extirpa- 
tion for  a  sarcomatous  goitre. 

Novaro,  1881,  and  Giommi,  1881,  each 
reported  a  total  extirpation  of  goitre. 

Pitts,  1881,  had  a  case  of  bronchocele 
in  which  the  thyroid  gland  was  removed 
during  an  attack  of  dyspnea. 

Piccinelli,  1S81,  contributed  his  ob- 
servations on  the  extirpation  of  cystic 
goitre. 

Falkson,  i8Sr,  and  Fiorani,  1881,  each 
expatiated  on  goitre. 

Tillax,  18S1,  reported  ablation  for  ex- 
ophthalmic goitre  and  sarcoma  of  the  thy- 
roid gland. 

Barker,  1882,  reported  a  small  goitre 
producing  great  difficulty  on  exertion ; 
excision  ;   recovery  and  complete  relief, 

Pietrzikowski,  1882,  made  extirpation 
for  carcinomatous  goitre. 

Englisch,  1882,  and  DeRoubaix,  1882, 
each  reported  an  excision  for  a  parenchy- 
matous goitre. 

Wyeth,  1882,  reported  some  cases  of 
goitre  recently  treated  by  excision. 

Bouilly,  18S2,  reported  a  thyroidectomy 
followed  by  infection  and  death. 

Pozzi,  1883,  had  a  case  of  parenchy- 
matous and  cystic  goitre. 

Bennett,  1883,  reported  a  case  of  ex- 
cision of  a  large  bronchocele,  with  pre- 
liminary tracheotomy. 

Fuller,  18S3,  reported  the  removal  of 
the  thyroid  gland  in  parts. 

Pozzi,  1883,  had  a  case  of  parenchy- 
matous and  cystic  goitre  with  compression 
of  the  trachea.  An  extirpation  was  per- 
formed after  a  tracheotomy ;  the  forci- 
pressure  was  used  for  forty-eight  hours ;  a 
second  hemorrhage  occurred,  resulting  in 
death. 

Brugia,  1883,  reported  a  case  of  folli- 
cular goitre  cured  by  extirpation  of  the 
thyroid  gland. 


SURGERY  OF  THE   THTROID. 


213 


Delens,  1S83,  reported  his  observations 
on  thyroidectomy. 

Jones,  1883,  reported  on  enlargement 
of  the  thyroid  gland  in  a  male,  producing 
pressure  on  the  trachea  and  serious  attacks 
of  dyspnea  ;  removal  of  isthmus  ;  atrophy 
of  lateral  lobes  ;   cure, 

lieckel,  1S84,  removed  a  sarcomatous 
goitre,  with  recovery. 

Rehu,  1884,  removed  a  cystic  goitre, 
resulting  in  death. 

Jankowski,  1884,  reported  a  case  where 
paralysis  of  the  larynx  resulted  after  ex- 
cision of  goitre. 

Mazzoni,  1884,  made  an  incision  in  the 
latteral  lobe  of  the  thyroid  for  aneurys- 
matic  goitre. 

Weinlachner,  1884,  and  Ilieguet,  18S4, 
each  made  a  thyroidectomy  for  adeno- 
cystic  goitre. 

Fitzgerald,  1884,  published  his  notes  on 
a  successful  removal  of  a  large  goitre. 

Marchand,  1884,  completely  extirpated 
the  thyroid  gland  for  cancer. 

Jones,  1884,  reported  two  cases  of  dis- 
eases of  the  thyroid  gland ;  removal  of 
isthmus  and  part  of  lateral  lobes  ;  cured. 

Billroth,  1884,  made  a  total  extirpation 
of  the  goitre. 

Saltman,  1884,  reported  on  the  removal 
of  the  thyroid  gland  and  its  consequences. 
Mudd  reported  an  extirpation  of  a  thy- 
roid gland  weighing  sixteen  and  one-half 
ounces  ;   recovery. 

Allara,  1885,  made  an  extirpation  of 
the  thyroid  gland,  and  Hack,  1886,  on 
treatment  for  exophthalmic  goitre. 

Weinlechner,  1886,  had  a  case  of  double 
parenchymatous  goitre  on  which  he  oper- 
ated, making  an  extirpation  ;  patient  col- 
lapsed half  an  hour  after  operation. 

Hlroea,  1886,  reported  a  thyroidectomy, 
and  Tassi,  1887,  an  extirpation  of  the 
thyroid  gland. 

Avtokratoff,  1887,  recorded  the  effect 
of  extirpation  of  thyroid  gland  from  ani- 
mals on  the  central  nervous  system. 

Morris,  1887,  reported  two  cases  of  dis- 
eases of  the  thyroid,  one  treated  by  ex- 
cision, the  other  by  injection  of  iodine; 
recovery. 

Sanquirico  and  Orecchia,  1887,  extir- 
pated the  thyroid  gland. 

Weir,  1887,  removed  a  tumor  of  the 
thyroid  by  Socin's  method, 

vSavory  and  Parker  reported  on  the 
removal  of  a  thyroid  cyst,  followed  by 
ulceration,  opening  into  the  trachea. 


Von  Nussbaum,  18S7,  made  an  ampu- 
tation of  a  goitrous  gland. 

Lenger,  1887,  removed  a  suffocative 
goitre. 

Browne,  1888,  reported  cases  of  partial 
removal  of  goitre. 

Lupo,  1888,  made  a  contribution  to  the 
study  of  thyroidectomy. 

Welch,  1888,  exhibited  microscopical 
specimens  of  the  thyroid  gland  after  par- 
tial extirpation. 

Matas,  1888,  reported  on  a  case  of  thy- 
roidectomy for  malignant  disease,  with  a 
synoptical  consideration  of  the  present 
status  of  this  operation. 

Phelps,  1888,  reported  on  the  removal 
of  the  thyroid  gland. 

Harsant,  18S8,  made  observations  of 
cases  illustrating  the  surgery  of  the  thy- 
roid gland. 

Kocher,  1889,  reported  250  extirpations 
of  the  thyroid  gland. 

Pascale,  1889,  reported  on  extirpation 
of  the  thyroid  gland. 

Schott,  1S89;  Stierlin,  1889,  and  Audry, 
1889,  each  extirpated  for  exophthalmic 
goitre. 

Cheever,  1889,  reported  on  thyroid 
tumor  ;  a  large  double  bronchocele,  weigh- 
ing ten  and  a  half  ounces  ;  excised  ;  death 
resulting  from  impaired  inspiratory  power 
and  from  shock. 

Berger,  1S89,  made  a  thyroidectomy  for 
epithelioma  of  the  thyroid  gland. 

Symonds,  1889,  reported  eight  cases  of 
thyroid  cysts  and  adenomata  treated  by 
extirpation. 

Martina,  1890,  advocated  total  extirpa- 
tion for  goitre. 

Levitan,  1890,  reported  on  the  new 
methods  of  surgical  treatment  of  goitre  in 
general  and  on  resection  by  ]\Jikulicz's 
method  in  particular. 

Eghetti,  1890,  made  extirpation  of  the 
thyroid  gland  for  goitre. 

Tizzoni  and  Centanni,  1890,  reported 
on  the  effect  of  thyroidectomy. 

Borghi,  1891,  extirpated  a  suffocative 
goitre. 

Gley,  1891,  contributed  a  study  on  ex- 
cision of  the  thyroid  gland  and  its  func- 
tions. 

Arthaud  and  Magon,  1891,  reported  on 
harmless  ablation  of  the  thyroid  gland  and 
the  cause  of  the  grave  accidents  of  thyroi- 
dectomy. 

Lemke,  1891,  reported  a  fatal  extir' 
pation  for  exophthalmic  goitre. 


3X4 


SURGERT  OF  THE   THYROID. 


Zadlmann,  1893,  reported  seven  cases 
of  extirpation  for  goitre. 

Gley,  1892,  made  new  researches  of  the 
effects  of  thyroidectomy  on  a  rabbit,  and 
Moussu,  1892,  reported  on  the  effects  of 
thyroidectomy  performed  on  domesticated 
animals. 

Lannelongue,  1892,  reported  partial 
thyroidectomy. 

Gamalieya,  1892,  had  two  cases  of  ex- 
cision of  goitre. 

Schwarz,  1892,  made  a  successful  thy- 
roidectomy. 

Collier,  1893,  removed  a  large  tumor  of 
the  thyroid  gland,  with  recovery. 

Levings,  1893,  reported  two  cases  of 
partial  thyroidectomy,  and  Kent,  1893, 
used  thyroid  extract  after  thyroidec- 
tomy. 

Thiriar,  1893,  made  a  total  thyroidec- 
tomy for  an  enormous  goitre ;  death  by 
tetanus. 

Fostemski,  1894,  reported  on  partial 
extirpation  of  the  thyroid  gland. 

Ranschoff,  1894,  reported  on  thyroi- 
dectomy for  thyroid  abscess  ;  recovery. 

Roberts,  1894,  advocated  thyroidectomy 
in  the  treament  of  goitre. 

Booth  and  Curtis,  189.1,  performed  thy- 
roidectomy for  exophthalmic  goitre. 

Briner,  Solary  and  Newton,  1894, 
treated  exophthalmic  goitre  by  thyroidec- 
tomy. 

Booth,  1894,  gave  a  brief  review  of  the 
thyroid  theory  in  Graves'  disease,  with 
report  of  two  cases  treated  by  thyroidec- 
tomy. 

Gley  and  Rochon-Duvigneaud,  1894, 
contributed  a  study  on  excision  of  the 
thyroid  gland  performed  on  animals. 

Nicholas,  1894,  reported  on  the  effect 
of  thyroidectomy  on  a  salamander. 

Dalziel,  1894,  exhibited  a  specimen  of 
cystic  adenoma  of  the  thyroid  removed  by 
operation. 

Pean,  1894,  reported  an  excision  of  the 
thyroid  gland  followed  by  complications 
resulting  in  temporary  dysphonia. 

Bocardi,  1894,  made  ablation  for  goitre. 

Gley,  1894,  remarks  on  the  subject  of 
the  communication  of  Launalic  on  toxi- 
city in  the  urine  of  dogs  after  having  thy- 
roidectomies. 

Semmola,  1894,  performed  thyroidec- 
tomies on  dogs,  and  Rouxeau,  1894,  con- 
tributed a  study  on  the  excision  of  the 
thyroid  in  rabbits. 

Sata,  lleydenreich,  Pochazka  and  Mus- 


kovec,   1895,   each   made   thyroidectomies 
for  exophthalmic  goitre. 

Coley,  1895,  and  Schafer,  1895,  each 
removed  a  parenchymatous  exophthalmic 
goitre  by  excision. 

Starr,  1896,  reported  on  the  nature  and 
treatment  of  exophthalmic  goitre  with 
special  reference  to  the  thyroid  theory  of 
the  disease  and  to  the  treatment  by  thyroi- 
dectomy. 

Goujon,  1895,  made  thyroidectomy  and 
the  use  of  the  extract  of  thyroid  after 
operation. 

Spencer,  1895,  made  report  on  fibrosis 
of  thyroid  ;  partial  thyroidectomy  ;  trache- 
otomy and  dilatation  of  the  stenosed 
trachea. 

Sheen,  1895,  excised  cystic  thyroid; 
death. 

Capobianco,  1895,  reports  a  thyroidec- 
tomy. 

Masoin,  1895,  reported  on  the  influence 
of  extirpation  of  the  thyroid  gland  with 
the  quantity  of  oxyhemoglobin  in  the  con- 
tents of  the  blood. 

Thiriar,  1896,  made  an  excision  of  a 
parenchymatous  goitre. 

Stokes  reported  a  case  of  large  cystic 
bronchocele  necessitating  complete  re- 
moval of  the  thyroid  gland. 

Berard,  1896,  contributed  his  observa- 
tions on'  the  effects  of  thyroidectomy. 

Katzenstein,  1896,  made  an  extirpation 
of  the  thyroid  gland. 

ISIurray,  1896,  reported  on  some  of  the 
effects  of  thyroidectomy  in  the  lower 
animals. 

Vorhoef,  1896,  advocated  thyroidectomy 
for  exophthalmic  goitre. 

Morton,  1896,  reported  on  the  causation 
and  treatment  of  sudden  dyspnea  in 
goitre,  with  report  of  a  case  in  which  the 
middle  lobe  of  the  thyroid  was  excised. 

Rouxeau,  1896,  experimented  by  ex- 
cision of  the  thyroid  gland  on  the  rabbit. 

Johnson,  1897,  reported  on  extirpation 
of  a  retrosternal  tumor  of  the  thyroid. 

Pokrovsky,  1896,  reported  on  the  influ- 
ence of  extirpation  of  the  thyroid  gland, 
in  a  dog,  on  the  quantities  and  qualities 
of  the  white  globules  in  the  blood. 

IMercier,  1897,  reported  a  case  of  par- 
tial thyroidectomy. 

Saenger,  1897,  excised  the  thyroid 
gland  for  exophthalmic  goitre. 

Jonnesco,  1897,  made  thyroidectomy 
for  exophthalmic  goitre,  coexistent  with 
epilepsy. 


SURGERY  OF  THE   THYROID. 


215 


Inouye,  1S97,  made  an  excision  of  the 
right  thyroid  gland. 

Doyen,  11^97  ;  Pean,  1897;  and  Sorgo, 
1897,  each  made  an  excision  for  exoph- 
thalmic goitre. 

Schulz  and  Jonnesco,  1897,  each  re- 
moved the  thyroid  gland  for  exophthalmic 
goitre. 

Reverdin  and  Buscarlet,  1897,  reported 
extirpation  for  suffocative  neoplastic 
goitre, 

Rouxeau,  1897,  reported  three  hundred 
operations  and  thyroidectomies  on  the 
rabbit. 

Cathercart,  1S98,  removed  a  tumor  of 
the  thyroid  gland. 

Takaki,  1898,  made  extirpation  of  right 
lobe  and  isthmus  of  hypertrophied  thyroid 
gland  ;  recovery. 

Gray,  1898,  gave  notes  on  a  case  of  ex- 
ophthalmic goitre ;  removal  of  half  the 
thyroid  gland. 

Thomson,  1896,  made  a  total  extir- 
pation of  the  thyroid  gland  for  exoph- 
thalmic goitre. 

Jaboulay,  1898,  made  an  excision  for 
exophthalmic  goitre. 

Booth,  1898,  reported  on  the  results 
obtained  by  the  operations  of  partial  thy- 
roidectomy in  eight  cases  of  Graves'  dis- 
ease, 

Hampel,  1898,  contributed  further  ob- 
servations on  the  effects  of  partial  thyroi- 
dectomy. 

Takaki,  1898,  made  an  extirpation  of  the 
right  lobe  and  isthmus  of  hypertrophied 
thyroid  gland  ;   recovery. 

Levy,  1898,  reported  on  blood  changes 
after  experimental  thyroidectomy. 

Apopenko,  1898,  reported  on  the  effect 
of  thyroidectomy  on  the  growth  and  de- 
velopment of  the  bony  and  nervous  sys- 
tem in  young  animals. 

Gibert,  1898,  reported  a  :iew  theory  of 
ablation  of  the  thyroid  gland. 

Sandelin,  1898,  made  one  hundred  thy- 
roidectomies. 

Keen,  1899,  reported  good  results  from 
an  operation  for  exophthalmic  goitre  by 
excision,  and  Pollard,  1899,  had  a  case  of 
exophthalmic  goitre  treated  by  extirpation 
of  thyroid  gland,  with  recovery. 

Doepfuer,  1899,  and  Nicoli,  1899,  each 
reported  a  case  of  exophthalmic  goitre  in 
which  the  thyroid  gland  was  excised. 

McCosh,  1899,  reported  on  aphonia  fol- 
lowing extirpation  of  goitre. 

Berry,  1900,  gave  his  notes  on  seventy- 


two  consecutive  cases  of  removal  of  goitre 
by  operation. 

Bennecke,  1900;  Reverdin,  1900;  and 
Witmer,  1900,  each  made  an  excision  of  the 
thyroid  gland  for  exophthalmic  goitre. 

Klemperer,  1900,  reported  a  fatal  re- 
moval of  thyroid  gland  for  exophthalmic 
goitre. 

Witherspoon,  1903,  recorded  eight  par- 
tial thyroidectomies ;  seven  cases ;  one 
death  for  exophthalmic  goitre. 

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2l8 


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Levitan.     Meditisma,  St.  Petersburg,  1890,  ii, 

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Barth.     Wurzburg,  1890. 

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SURGERY  OF  THE   THYROID. 


Zahlmann.  Hosp.  tid,  kjobenh.,  1892,  3  R, 
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Bode.     Berlin  klinik,  1892,  44  hft.,  i  23. 

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Bottini.     Clin,  chir.,  Miiano,  1894,  ">  97-130. 


SURGERY  OF  THE   THTROTD. 


Von   Eiselberg.     Arch.    f.    klin.  chir.,  Berlin, 

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D'Amore,  Falcone  et  GiofFredi.  Atti  d.  xi 
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Semmola.     Cong    franc,  de  med.,  1894,  Paris, 

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Gaz.  med.  de  Nantes,  1894-5,  xiii,  in. 

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Gley  and  Physalix,  Atti  d.  cong.  med.  inter- 
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Paladino.  Atti  d.  r.  accad.  med.  chir.  di 
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Postempski.     Bull.  d.  r.  accad.  med.  di  Roma, 

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Sato.  Koseikwan  iji.  krenkju  kwai  Zashi, 
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Bergeat.  Beitr.  z.  klin.  chir..  Tubing.,  1895-6, 
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Lancet,  New  York,  1895,  S^S- 

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McCosh.  Tr.  American  Surg.  Association, 
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Prochazka.  Casop.  let.  cesk.  v.  Praze,  1895, 
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Lanz.  Eruahungen  uber  die  schilddrusenthe- 
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Gaz.  d.  hop.,  Paris,  1895,  Ixviii,  833-840. 

Tahier.  Jour.  d.  bog.  med.  de  Lille,  1895,  '» 
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Masetti.  Riv.  sper.  di  freniat.,  Reggio,  Eme- 
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Brown.     Lancet,  London,  1895,  ii»  722. 

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Compt.  rend.  soc.  biol.,  Paris,  1895,  ii.  22. 

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Mikulicz.  Verhandl.  d.  deutschc  gesellsch.  f. 
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Bowlby.  Tr.  CUn,  Soc,,  London,  1895,  xxviii, 
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222 


SURGERT  OF  THE   THTROID. 


Allen.  Ann.  Surg.,  Philadelphia,  1897,  xxv, 
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Tuffier.  Gaz.  hebd.  de  med.,  Paris,  1897, 
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Rauzy.     Lyon,  1897. 

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Hanszel.   Wien.  klin.  woch..  1897,  x,  1008-1010. 

Gley.  Compt.  rend.  soc.  biol.,  Paris,  1897,  iv, 
18-20;   1897,  iv,  17. 

Rouxeau.  Arch,  de  physiol.  norm.  et.  path., 
Paris,  1897,  ix,  136-151. 

GrenkoiT.  Shorn,  protok.  obsh.  Kaluzh.  vrach, 
1897;  Kaluga,  1898,  xxxvi,  42-44. 

Bernays.     St.  Louis  Med.  Gaz.,  1898,  i,  45-48. 

Sandelin.  Res.  pp.  Ixix :  Ixxii,  Finska  lak- 
sallsk-handl.,  Helsingfors,  1898,  xl,  651-670. 

Krusen.     Therap.  Gaz.,  Detroit,  1898,  xiv,  516. 

Fontan.  Assoc,  franc,  de  chir.  proc.-verb., 
Paris,  1898,  xii,  542-548. 

Detwiler.  Therap.  Gaz.,  Detroit  1898,  xiv, 
508-510. 

Doyen.     Med.    Press  and    Circular,    London, 

1898,  Ixvi,  61. 

Walker.  Internat.  Clin.,  Philadelphia,  1898, 
8  s,  i,  221-223,  I  pl- 

Cathercart.  Tr.  Med.  Soc,  Edinburgh,  1898-9, 
xviii,  35  37- 

Rolando.  Boll.  d.  r.  accad.  med.  di  Genova, 
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Polk.  Ara.;Gynec.  and  Obst.  Journal,  New 
York,  1898,  xii,  201. 

Picque.  Bull,  et  mem.  soc.  chir.,  Paris,  1898, 
xxiv,  702. 

Takaki.  Sei-i  Kwai  Med.  Journal,  Tokyo, 
1898,  xvii,  453-455. 

Gray.  Intercolon.  Med.  Journal,  Melbourne, 
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Thomson.  Ilosp.  tid.  kjobenh.,  1898,  4  R,  vi, 
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France  med.,  Paris,  1898,  xiv,  17-19. 

iaboulay.     France  med.,  Paris,  1898,  xiv,  4  6. 
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Stokes,  Sir  W.  British  Med.  Journal,  London, 
1898,  ii,  1297. 

Wolff.  Mitt.  a.  d.  grenzgeb.  d.  med.  u.  chir., 
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217-20. 

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718-723. 


Edmunds.  Proc.  Roy.  Soc,  London,  1898, 
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Levy.  British  Med.  Journal,  London,  1898, 
ii,  608. 

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No.  3,  72-131. 

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Detwiller.  Penn«.ylvania  Med.  Journal,  Pitts- 
burg, 1898  9,  ii,  138  141. 

Krusen.     Therap.  Gaz.,  Detroit,  1898,  xiv,  516. 

Wiese.     Bonn,  1899. 

Keen.  New  Orleans  Med.  and  Surg.  Journal, 
1899  1900,  Iii,  386. 

Beatson.     Glasgow  Med.  Journal,  1899,  Ii,  57. 

Pollard.  British  Med.  Journal,  London,  1899, 
ii,  99S. 

Rehn.  Verhandl.  d.  gesellsch.  deutsch.  naturf. 
u.  aerzte,  1899,  Leipzig,  1900,  Ixxi,  pt.  2,  2  hfte., 
65  69. 

Jahrsb.  d.  schles  gesellsch.  f.  vaterl.  kult.,  1899, 
Bresl.,  1900,  Ixxvii,  i. 

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1899-1900,  xlix,  372  376. 

Nicoll.     Glasgow  Med.  Journal,  1899,  Hi,  203. 

McCosh.  Ann.  Surg.,  Philadelphia,  1899, 
XXX,  642. 

Schilling.  Munch,  med.  woch.,  1899,  xlvi, 
250  252. 

Bottini  clin.  chir.,  Milano,  1900,  viii,  833. 

Symonds.  Tr.  Clin.  Soc,  London,  1900, 
xxxiii,  218. 

Gondard.     Lyon,  1900. 

Viannay.  Province  med  ,  Lyon,  1900,  xiv,  403. 

Charon.  Ann.  soc.  Belgium  de  chir.,  Brussels, 
1900,  viii,  9296. 

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London,  1888-9;  London,  1900,  xviii,  233-244. 

Gondrand.     Lyon,  imp.,  1900,  No.  165,  50  p. 

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Capobianco  et  Mazziotti.  Arte  med.,  Napoli, 
1900,  ii,  543-6. 

Bennecke.  Deutsche  med.  woch.,  Leipzig  u. 
Berlin,  1900,  xxvi,  ver.-beil.,  87-88. 

Berry.  British  Med.  Journal,  London,  1900, 
ii,  3-ii,6fig. 

Reverdin.  Propagateur  med.,  Parii,  1900,  v, 
V,  7-12. 

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xxix,  191-243. 

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3".  329.  344.  3f^0- 

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1900,  vii,  165-182. 

Klemperer.  Therap.  d.  gegnew.,  Berlin  u. 
Wien,  1900,  ii,  536  541. 

Witherspoon.  Journal  Am.  Assn.,  July  25, 
1903,  p.  228-233. 

INTRA-GLANDULAR ENUCLEATION. 

Historical. — Porta,  of  Pava,  1840,  about 
the  first  to  operate,  Billroth,  1866,  did  it. 
Keser,  of  Vevy,  1887,  and  Symonds,  1889, 
each  operated  in  this  way. 

Lund,  1893,  reports  three  cases  of  thy- 
roid cyst  and  adenomata  treated  by  enu- 
cleation. 


SURGERr  OF  THE   TIITROID. 


223 


Mitrovich,  1894,  contributed  a  study  on 
enucleation  and  the  partial  extirpation  for 
goitre. 

Curtis,  1894,  reports  enucleation  for  an 
adenoma  of  the  thyroid. 

Brown,  1895,  notes  of  two  cases  of 
enucleation  of  thyroid  cyst. 

Schwartz,  1897,  reports  enucleation  for 
a  massive  goitre. 

Masi,  1899,  employed  enucleation  for 
goitre. 

Mailland,  1900,  on  enucleation  for  can- 
cer of  thyroid. 

Patel,  1900,  reported  a  case  of  benign 
tumor  of  the  thyroid  treated  by  enuclea- 
tion. 

BIBLIOGRAPHY. 

Schwartz.  Rev.  de  chir.,  Paris,  1888,  viii, 
988997. 

Lund.     Lancet,  London,  1893,  ii,  1384. 

Mitrovich.     Geneve,  1894. 

Curtis.  Internat.  Clin.,  Philadelphia,  1894,  4?, 
ii,  216-218. 

Brown.     Lancet,  London,  1895,  ii,  722. 

Bull.  acad.  de  med.,  Paris,  189C),  xxxvi,  507  5:1. 

Schwartz.  Rev.  gen.  de  clin,  et  de  therap., 
Paris,  i8y7,  xi,  593. 

Assoc,  franc,  de  chir.  proc.-verb.,  Paris,  1898, 

xii,  510-514- 

Masi.  Au  san  mil  ,  Buenos  Aires.  1899,  i, 
326330,  I  p). 

Mailland.     Lyon  med.,  1900,  xciii,  234. 

Patel.     Lyon  med.,  1900,  xciv,  408-410. 

Lyon  med.,  1900,  xciv.  50-52. 

LARYNGOTOMY. 

Weinlechner.  Aerztl.  berlin  d.  k.  k.  allg. 
krankenanst  zu  Wien  (1886),  1888,  212. 

EXOTHYROPEXY  (1892— I9O4). 

This  operation  was  first  practiced  by 
Jaboulay,  in  1892,  who  with  Berard  and 
other  of  his  colleagues  in  and  about  Lyons, 
did  many  operations  of  this  character  for 
both  parenchymatous  and  exophthalmic 
goitre.  The  gland  is  delivered  through 
an  incision  and  allowed  to  remain  so  until 
atrophy  of  the  gland  occurs  under  aseptic 
precautions.  The  operation  is  more  fre- 
quently made  in  France.  Poncet  aban- 
doned the  operation  because  of  the  high 
mortality  (23  per  cent.),  and  the  frequent 
recurrence  of  exophthalmic  disease  after 
this  procedure.  The  most  favorable 
growths  for  this  operation  are  those  most 
prominent;  but  little  time  and  knowledge 
is  required  to  perform  this  operation. 

Jaboulay  reports  35  cases, Lyons, France, 
1892;  Poncet,  15;  Blanc,  3;  Guillemont, 
3;  Pollosson,  5;  Rocket,  Albertin,  Bu- 
chanan and  Hartman,  each  i.     Total,  65. 

Mortality :    Berard  collected  65  opera- 


tions (some  of  which  were  exophthalmic), 
4  deaths  from  pneumonia,  2  from  septic 
infection  with  hemorrhage  and  acute  ex- 
ophthalmos ;  some  greatly  benefited,  others 
not.  Both  primary  and  secondary  hem- 
orrhage is  rare.  In  a  few  cases  it  may  be 
necessary  to  remove  the  manubrium  of  the 
sternum  that  the  gland  may  be  luxated. 

Historical.  —  Jaboulay,  1894,  con- 
tributed a  manual  on  the  operation  of  exo- 
thyropexy. 

Poncet  and  Jaboulay,  1894,  advise  the 
treatment  of  exothyropexy. 

Brissaud,  1894,  reported  a  case  of  ex- 
ophthalmic goitre, on  which  was  performed 
the  operatien  of  exothyropexy;   death. 

Hartmann,  1895,  performed  an  exo- 
thyropexy for  suffocative  goitre. 

Blanc,  1895,  contributed  his  observa- 
tions on  the  operations  of  exothyropexy 
for  suffocative  goitre. 

Albertin,  1895,  reports  an  exothyro- 
pexy. 

Nicolas,  1895,  advocates  exothyropexy 
for  suffocative  goitre. 

Naumann,  1S98,  reports  an  exothyro- 
pexy for  parenchymatous  goitre. 

Pollosson,  1899,  made  an  exothyropexy 
for  suffocative  goitre. 

BIBLIOGRAPHY. 

Jaboulay,     Lyon  mod.,  1894,  Ixxv,  491-494. 

Bull,  et  mem.  soc.  de  chir.,  Paris,  1894,  ^^» 
304-307- 

Med.  mod.,  Paris,  1894,  ^>  5^^- 

Poncet  and  Jaboulay.  Bull,  med.,  Paris,  1894, 
viii,  121-123. 

Brissaud.     Med.  mod.,  Paris,  1894,  t,  243  245. 

Med.  mod.,  Paris,  1894,  i^'  i93-i95- 

Hartmann.  Mercredi  med.,  Paris,  1895,  vi, 
123. 

Blanc.  Loire  med.,  St.  Etienne,  1895,  xiv, 
159  166. 

Albertin.  Areh.  prov.  de  chir.,  Paris,  1895,  iv, 
427. 

Nicolas.  Gaz.  d.  hop.  de  Toulouse,  1895,  i^. 
129. 

Nicolas.  Mem.  et  compt.  rend.  soc.  d.  sc. 
med.  de  Lyon  (1895),  1896,  xxxv,  pt.  2,  37-43. 

Severeanu.  Bull,  et  mem.  soc.  de  chir.  de  Bu- 
carest,  1898  9,  i,  128-134. 

Naumann.  Hygiea,  Stockholm,  1898,  Ix,  pt.  2, 
86. 

Lyon  med.,  1898,  Ixxxvii,  445. 

Pollosson.     Lyon  med.,  1899,  xcii,  303. 

INDIRECT  SURGERY LKiATION    SUPERIOR 

THYROID  ARTERY    (1779-I9O4). 

Ligation  of  the  arteries  supplying  the 
thyroid  gland  was  first  suggested  by  Bliz- 
ard  and  practiced  by  Moreau,  at  the  Hotel 
Dieu,  1779.  Blizard's  case  had  slough, 
secondary  hemorrhage  and  death.     Brodie 


334 


SURGERT  OF  THE   THYROID. 


disapproved  the  theory  upon  which  this 
operation  was  based,  Walthar,  1814, 
ligated  both  thyroid  arteries.  Coates, 
181S,  ligated  the  left  superior  thyroid  ar- 
tery. Mayor,  1822,  employed  ligation  of 
the  thyroid  artery  (and  other  associated 
vessels)  and  excision  combined.  This 
method  was  an  innovation  in  surgery  of 
the  thyroid  gland,  for  better  results  were 
accomplished  with  fever  complications 
during  the  operation  than  had  any  method 
previously  employed.  This  method  per- 
mitted the  removal  of  a  part  or  all  of  the 
gland  tumor  to  be  accomplished  with 
comparative  ease.  Rydygier,  1889,  col- 
lected 16  such  operations;  Gunther  col- 
lected 21  cases  of  ligature  of  the  superior 
thyroid  artery,  with  2  cures  and  3  deaths 
before  1875. 

Ligature  of  thyroid  arteries,  according 
to  Rehn,  gives  a  mortality  of  28.6  per 
cent ;  2.4  per  cent,  were  cured  and  50  per 
cent,  were  improved.  Regarding  this 
Balacesu  says  :  "  The  method  of  ligaturing 
the  thyroid  arteries  has  been  the  first  to 
be  abandoned  (among  operations  attack- 
ing the  thyroid  gland),  because  in  nearly 
all  cases  the  disease  recurred  in  a  few 
months  after  operation.  Secondly,  the 
execution  of  this  operation  was  difficult 
where  the  thyroid  was  very  large,  espe- 
cially in  cases  in  which  its  relations  to 
surrounding  tissues  was  altered  ;  or  it  pre- 
disposed to  secondary  hemorrhages  on  ac- 
count of  the  fragility  of  the  vessels. 
Kocher,  Kopp  and  Rehn,  have  recorded 
cases  in  which  this  operation  was  followed 
by  tetany. 

Historical. — Coates,  1819,  had  a  case 
of  bronchocele  in  which  the  superior  thy- 
roid artery  was  successfully  tied, 

Jameson,  1822,  reported  a  case  of  bron- 
chocele relieved  by  taking  up  one  of  the 
superior  thyroid  arteries. 

Langenbeck,  1823,  successfully  tied  the 
superior  thyroid  artery. 

Earle,  1826,  reported  a  case  of  broncho- 
cele in  which  the  superior  thyroid  arteries 
were  tied, 

Hoering,  1829,  succeeded  in  ligating 
the  superior  thyroid  artery  for  broncho- 
cele. 

Wells,  1832,  reported  a  deep-seated 
tumor  under  the  angle  of  the  jaw,  compli- 
cated with  bronchocele;  ligation  of  su- 
perior thyroid  artery. 

Hirtz,  1841,  ligatured  the  superior  thy- 
roid artery  for  goitre. 


Rigal  de  Gillac,  1841,  treated  a  goitre 
by  ligature  of  the  superior  thyroid  artery. 

Marzuttini,  1846,  reported  a  highly 
inflamed  goitre  treated  by  ligature  of  the 
superior  thyroid  artery. 

Weickert  and  Eickmann,  1847,  ^^^h 
reported  ligaturing  of  the  superior  thyroid 
artery. 

Porta,  1850,  reported  a  cure  of  broncho- 
cele by  tying  the  superior  thyroid  artery. 

Alquie,  1854,  ligated  the  superior  thy- 
roid artery  for  suffocative  goitre, 

Richter,  i860,  successfully  ligated  the 
superior  thyroid  artery. 

Berruti,  1879,  treated  bronchocele  by 
ligature  of  the  superior  thyroid  artery. 

Karli,  1879,  reported  a  ligaturing  of 
the  thyroid  artery. 

Downes,  1881,  treated  a  pulsating 
bronchocele  by  ligature  of  the  thyroid 
vessels  ;   relief. 

Lejars  and  Le  Roy,  18S8,  for  suppura- 
tion, ligated  the  superior  thyroid  artery ; 
death. 

Hurwitz,  1887,  reported  a  ligature  of 
the  superior  thyroid  artery. 

Weinleichner,  Billroth  and  Rydygier 
each  reported  a  ligature  of  the  superior 
thyroid  artery. 

Rydygier,  1890,  treated  bronchocele  by 
ligature  of  the  superior  thyroid  artery. 

Koller,  1891,  successfully  tied  the  su- 
perior thyroid  artery. 

BIBLIOGRAPHY. 

Coates.      Med.-Chir.   Tr.,    London,    1819,    x, 

312  314- 

Jameson.  Am.  Med.  Recorder,  Philadelphia, 
1822,  V,  116. 

Langenbeck.  N.  biblioth.  f.  d.  chir.  u.  opth., 
Hannov,,  1823-8,  iv,  558,617,  i  pi. 

Weistiog.     Heidelbergea,  1823. 

Gior.  d.  chir.  prat.,  Trento,  1825,  i,  524  530. 

Earle.  London  Med.  and  Phys.  Journal,  1826, 
i,  201-205,  1  pi. 

Hoering.     Mag.  f.  d.  ges.  heilk.,  Berlin,  1829, 

vii.  314-331- 

Wells.  Am.  Jour.  Med.  Sc,  Philadelphia, 
1832,  X,  33. 

Lancet,  London,  1832,  ii,  479. 

Laymann.     Bonn,  1833. 

Lancet,  London,  1840  41,  i,  691. 

Hirtz.     Gaz.  med.  de  Paris,  1841,  ix,  9. 

Rigal  de  Gaillac.  Bull.  gen.  de  therap.,  Paris, 
1841,  xxi,  224-230. 

iviarzuttini.  Bull.  d.  sc.  med.  di  Bologna,  1846, 
ix,  365-370. 

Weickert.  Jour.  d.  chir.  u.  augenh.,  Berlin, 
1847,  xxxvii,  396  398. 

Eichmann.     Med.  ztg.,  Berlin,  1847,  xvi,  251. 

Porta.  Ann.  univ.  di  med.,  Milano,  1850, 
cxxxvi,  5. 

Alquie.  Ann.  clin.  de  Muntpel.,  1854  5,  ii, 
222-4. 


SURGERY  OF  THE   Tin'ROID. 


225 


Ztschr.  med.  chir.  u.  geburtsh.,  Magdeb.,  1855, 
ix,  .^81-384. 

Richter.     Leipzig,  i860. 

Perassi.     Gior.  d.  r.  acad.  di  med.  di  Torino, 

1878,  xli,  389-396. 

Berruti.     Gior.    d.    r.    acad.    di    med.,  Torino, 

1879,  xxvi,  140  148. 
Karli.     Berne,  1879. 

Dovvnes.     Lancet,  London,  1881,  i,  458. 

Lejars  and  Le  Roy.  Bull.  soc.  anat.,  Paris, 
1886,  Ixi,  611-614. 

Wolrier.  Wien.  med.  woch.,  1886,  xxxvi, 
1013-1052. 

Hurwitz.     Wurzburg,  1887. 

Falcone  La.  Gaz.  d.  osp.,  Milano,  1887,  viii, 
217. 

Verhandl.  d.  deutsch  gesellsch.  f.  chir.,  Ber- 
lin, 1887,  xvi,  pt.  i,  93. 

Weinleichner.  Deutsche  med.  woch.,  Berlin, 
1888,  xii,  841. 

Billroth.     Wien.  klin.  woch.,  1888,  i,  3-5. 

Rydygier.  Wien.  med.  woch.,  1888,  xxxviii, 
1633,  1665. 

Rydygier.  Verhandl.  d.  dautsch.  gesellsch.  f. 
chir.,  Berlin,  1890,  xix,  pt.  2,  47-58. 

KoUer.     Bonn,  Siegsburg,   1891 ;  Lund.,  1892. 

Ann.  soc.  Belgium  de  chir.,  Brussels,  1893  4'  '1 
16  22. 

Iricomini.     II  policlinico,  Roma,  1896. 

Jonnesco.  Revue  chirurgicale,  Nov.  1897, 
supplement. 

Booth.     Med.  Record,  August  13,  1898. 

Rehn.     Munch,  med.  woch.,  Oct.  1899. 

Balacesu.  Archiv  fur  klin.  chirurgie,  1902 
(Vol.  67). 

Sorgo.  Centralbl.  f.  grenzgeb.  der  medicin. 
No.  I,  p.  329. 

COMPRESSION  TREATMENT    (1817-I9O4). 

The  treatment  of  goitre  by  compression 
was  suggested  and  practiced  by  Holbrook 
in  1817,  since  which  time  there  have  been 
several  cases  cured  by  this  method.  There 
are  comparatively  few  of  any  kind  of 
goitre  benefited  by  compression.  These 
few  reports  are  not  sufficient  evidence  to 
commend  its  uses.  Any  degree  of  pres- 
sure that  would  be  of  benefit  would  in  all 
probability  cause  troublesome,  if  not  dan- 
gerous, effects  upon  the  trachea  and  blood- 
vessels, one  or  all.  Compression  cannot 
be  classed  other  than  an  irrational  method 
of  treating  any  form  of  enlargement  of  the 
thyroid  gland. 

Historical. — Knafll,  1840,  treated  goitre 
by  compression. 

Dwight,  1850,  treated  bronchocele  by 
compression. 

Newman,  1858,  reported  a  case  of  com- 
pression of  the  trachea  by  enlarged  thy- 
roid ;  laryngotomy  ;   post-mortem. 

Brunelli,  1861,  reported  a  case  of  goitre 
with  hemorrhage,  which  he  treated  by 
compression  ;   permanent  recovery. 

Arnott,  1874,  had  a  case  of  simple  goitre 


resisting  ordinary  treatment  cured  by 
pressure. 

Clarke,  1890,  treated  goitre  by  com- 
pression ;   recovery. 

Le  Beck,  1896,  used  compression  in 
cystic  goitre. 

BIBLIOGRAPHY. 

Holbrook.  London  Med.  Report,  1817,  viii, 
288  290. 

Knafll.  Med.  jahrb.  d.  k.  k  oster  saates,  Wien, 
1840,  xxxii,  56  58. 

Dwight.  Buffalo  Med.  Journal,  1850  51,  vi, 
458-470. 

Newman.  Med.  Times  and  Gazette,  London, 
1858,  xvi,  554. 

Brunelli.  Gaz.  med.  d.  Orient,  Constanti- 
nople, 1861,  iv,  83-85. 

Dickinson.  Tr.  Path.  Soc,  London,  1861,  xii, 
229. 

Arnott.  St.  Thomas  Hosp.  Report,  London, 
1874,  '^.  273  5. 

Clarke.     Lancet,  London,  1890,  u,  446. 

LeBeck.  France  med.,  Paris,  1896,  xliii,  49- 
51- 

TRACHEOTOMY  (184O-I9O3). 

Tracheotomy  is  sometimes  resorted  to 
when  the  trachea  is  becoming  occluded 
from  pressure  of  a  thyroid  cyst  or  neo- 
plasm. Now  that  the  removal  of  the  thy- 
roid gland  has  become  so  perfected  it  is 
seldom  necessary  to  resort  to  opening  the 
trachea,  unless  it  should  become  suddenly 
occluded  as  the  result  of  pressure  from 
hemorrhage  ;  even  in  such  an  event  there 
is  usually  ample  time  to  give  relief  by  other 
methods. 

Historical. — King,  1S65,  reported  a 
tumor  of  thyroid  gland ;  tracheotomy  ; 
death. 

Stahl,  1868,  performed  a  tracheotomy 
on  a  hypertrophied  thyroid  gland. 

Chaboureau,  1869,  reported  a  tracheot- 
omy for  goitre. 

Jessop,  1872,  reported  a  case  of  bron- 
chocele giving  rise  to  dysphonia  ;  trache- 
otomy ;  subsequent  death  from  phthisis; 
trachea  compressed  by  the  enlarged  thy- 
roid body. 

Bottini,  1880,  performed  a  tracheotomy 
for  adenoma  of  the  thyroid  gland. 

Terillon,  1880,  reported  a  case  of  suffo- 
cative goitre  treated  by  tracheotomy. 

Zwicke,  1882,  reported  tracheotomy  for 
a  parenchymatous  goitre. 

Terrillon,  1883,  performed  a  successful 
tracheotomy  for  suffocative  goitre  with 
asphyxia. 

Graham,  1884,  had  a  case  of  goitre  with 
obstruction,  which  was  operated  by  trache- 
otomy,    lie  also  contributed  his  observa- 


326 


SURGERT  OF  THE   THYROID. 


tions  on  trachea-tubes  and  the  modified 
tubes  for  low  tracheotomy. 

Curgenven,  1890,  reported  goitre  in  a 
boy  causing  softening  of  tracheal  car- 
tilages; tracheotomy;   death, 

Gangolphe,  1893,  performed  tracheot- 
omy for  sufiFocative  goitre,  with  recovery. 

Casati,  1894,  reported  a  case  of  volumi- 
nous parenchymatous  goitre,  in  which  a 
tracheotomy  was  performed. 

Moinel,  1895,  reported  a  fatal  tracheot- 
omy for  goitre. 

Gayet,  1895.  described  a  case  of  cancer 
of  the  thyroid  gland,  which  spread  to  the 
trachea.  A  tracheotomy  was  performed, 
resulting  in  death. 

BIBLIOGRAPHY. 

Hughes.  Tr.  Path.  Soc,  London,  1848-50,  ii, 
130  132,  Berlin,  1848,  xvi,  252  255. 

Mettenheimer.  Wurzb.  med.  ztschr.,  1862,  iii, 
308  320,  I  pi. 

King.     British   Med.    Journal,    London,  1865, 

i»  5- 

Stahl.     Berlin,  1866. 

Chaboureau.     Strassbourg,  1869. 

Jessop.  British  Med.  Journal,  London,  1872, 
ii,  498. 

See.  Bull,  et  mem.  soc.  de  chir.,  Paris,  1876, 
ii,  72Q-731. 

Hutchinson.  British  Med.  Journal,  London, 
1876,  ii,  275. 

Bresgen.  Deutsche  med.  woch.,  Berlin,  1876, 
ii,  318-320. 


Lauzet.     Marseille  med.,  1876,  xiii,  343-347. 

Casson.  British  Med.  Journal,  London,  1877, 
i,  12. 

Schnitzler.  Wien.  med.  presse,  1877,  xviii, 
1836  1866. 

Donon.     Paris,  1879. 

Maas.     Breslau  med.  ztschr.,  1880,  ii,  145. 

Vedrenes.  Bull,  et  mem.  soc.  de  chir.,  Paris, 
1880,  Ti,  62-67. 

Bottini.     Osservatore,   Torino,   1880,  xvi,  132- 

134- 
Terillon.    Bull.  et.  mem.  soc.  chir.,  Paris,  1880, 

vi,  394398. 

Zwicke.     Charite  ann.,  Berlin,  1882,  vii,  505. 

Terrillon.  Ann.  d.  mal.  de  I'oreille  et  du 
larynx,  Paris,  1883. 

Labbe.  Ann.  d  mal.  de  I'oreille  du  larynx, 
Paris,  1883,  ix,  146  9. 

Graham.  Tr.  111.  Med.  Soc,  1884,  xxxiv, 
160-166,  I  pi. 

White.     British  Med.  Journal,  London,  1885, 

".  342. 

Curgenven.     Lancet,  London,  1890,  i,  598. 

Von  Bamberger.  Jahrb.  d.  Wien.  k.  k.  krank- 
enannst.  (1882),  1893,  i>  ^48- 

Gangolphe.  Province  med.,  Lyon,  1893,  ^"> 
146. 

Ewald.     Vrtljschr.   f.   gerichtl.   med.,  Berlin, 

1894,  3  ^>  '^i".  Supbl.  hft.  33  47. 

Cacati.  Atti  accad.  d.  sc.  med.  e  nat.  in  Fer- 
rara,  1894  5,  l^'x. 

Moinel.     Arch,  de  med.  et  pharm.  mil.,  Paris, 

1895,  ^x'«'i.  123-127. 

Gayet.  Arch.  prov.  de  chir.,  Paris,  1895,  iv, 
7i8  724. 

Delore.     Lyon  med.,  1897,  Ixxxv,  480-3. 
Belloli.     Lucina,  Bologna,  i8y8,  iii,  i82-i87. 
Rev.  de  chir.,  Paris,  1899,  xix,  440. 


THE    END, 


[Reprinted  from  American  Medicine,  Vol.  VII,  No.  25,  pages  983-987, 
June  18,  1904.) 


SURGERY  OF  HYDROCEPHALUS.* 
A  Historic  Review. 

BY 

BENJAMIN   MERRILL  RICKETTS,  Ph.B.,  M.D., 

of  Ciucinuati,  Ohio. 
Surgery  of  Hydrocephalus. 

(1744-1903.) 

(a)  Aspiration  cranial — spinal  subcutaneous. 

(b)  Compression. 

(c)  Seton. 

(d)  Injection. 

(8)  Internal  treatment. 

(f )  Topical  treatment. 

(g)  Electric  treatment, 
(h)  Conclusions. 

(i)  Pathology. 

Chapter  I. 

Aspiration. — This  method  has  been  most  universally 
employed.  There  is  some  difference  of  opinion  as  to 
where  the  trocar  should  be  made  to  enter  the  place  from 
which  the  fluid  is  to  escape.  The  principal  caution  to 
be  observed  is  injury  to  bloodvessels  and  sinuses.  When 
possible  the  opening  should  be  made  in  the  fontanels. 
When  the  ventricles  are  involved  the  site  of  tapping  js 
at  the  lateral  angle  of  the  anterior  or  posterior  fontanel 
because  of  the  absence  in  this  locality  of  vessels  and 
sinuses. 

An  opening  in  the  basilar  arachnoid  cavity  is  some- 
times best,  and  the  arachnoid  cavity  should  be  opened 
before  the  cyst  of  spina  bifida  is  punctured  when  this  is 
an  associated  condition.  When  such  exists  the  canula 
may  be  inserted  above  the  spina  bifida  for  temporary 
drainage  until  the  incision  in  the  spina  bifida  sac  has 
become  united. 

Dr.  Stevens  proposed  trephining  the  cranium  of  Dean 
Swift  in  1745 ;  this  is  the  first  recorded  suggestion  for 
this  operation.  Dionis'  suggests  draining  the  arachnoid 
cavity  through  the  various  sutures  and  fontanels. 

Le  Cat,  October  23,  1744,  punctured  for  hydroceph- 
alus. 

♦Read  before  the  Western  Surgical  and  Gynecological  Association, 
Denver,  Colo.,  December  28-29,  l9o3. 


Rommot,  of  Plymouth,  1778,  used  tho  trocar  in  re- 
moving 80  ounces  of  fluid  from  a  patient  witli  liydro- 
cephalus. 

One  of  the  earlier  reports  on  surgical  operations  for 
hydrocephalus  was  by  Odier,  1785. 

Vose,  1818,  successfully  treated  hydrocephalus  by  a 
surgical  operation  in  which  he  removed  the  fluid. 


12,584,  U  W.  Museum.— Hydrocepbalns.  Plaster  cast  of  head  of  adult 
male,  showing  hydrocephalus.  Measures  21..5  inches  sagitally  lioni 
nasal  point  to  inion  j  21  inches  coroiially  between  tips  of  ears;  and 
25  inches  horizontally  on  level  of  glabella. 

Textor,  1821,  no  doubt  prompted  by  the  brilliant 
results  ()l)tained  by  Vose,  succeeded  in  benefiting  an 
extreme  hydroccplialus  by  a.spirati(»n. 

During  the  year  1821,  Lizars,  Frcckleton  and  lU'la- 
field  each  operated  for  this  condition,  with  more  or  less 
benefit. 

3Iichaelis,  1S22,  employed  paracentesis  for  hydro- 
cephalus. 


Fenoglio,  1823,  punctured  the  subdural  space  for  the 
accumulation  of  fluid  resulting  from  injury. 

Ruppius,  1823,  removed  the  fluid  by  trocar  in  a  case 
of  hydrocephalus. 

Gray,  1825,  records  a  case  of  hydrocephalus  in  a  child 
9  months  old,  in  which  the  head  was  tapped  three 
times. 

Sym,  1826,  and  McComb,  1831,  each  report  repeated 
puncture  in  a  case  of  chronic  hydrocephalus. 

Dubrueil,  1837,  mentions  a  case  of  the  voluminous 
formation  of  fluid  in  the  meningeal  cavities  relieved  by 
puncture  through  the  occiput. 

Conquest,  1837,  mentions  tapping  the  head  in  19  cases 
of  hydrocephalus,  once  successfully. 

Kilgour,  1840,  records  two  such  cases,  in  which  oper- 
ation was  done  by  puncture. 

Petit,  Huster,  Boerhaave,  De  la  Motte,  Pare,  Portal, 
Richter,  Golis,  Breschet,  Bayer,  Dupuytren,  and  Physick, 
each  condemned  the  trocar. 

Battersby  ^  also  condemned  its  use  for  hydrocephalus. 

West,  1842,  before  the  days  of  aseptic  surgery,  col- 
lected 55  cases  of  tapping  for  hydrocephalus,  with  40 
deaths  and  15  cures.  Fifteen  appeared  at  birth;  36 
before  6  months  of  age,  and  4  not  given. 

Dickinson  reported  26  cases;  4  began  at  birth,  16 
before  6  months,  and  6  near  2  years. 

Edward,  1846,  cured  a  patient  with  hydrocephalus  by 
puncture  and  drainage,  as  did  also  Kilsell  in  1849. 

Battersby,  1850,  reports  three  cases  of  congeuitid 
hydrocephalus,  in  which  he  employed  puncture  with  the 
evacuation  of  sanguineous  fluid. 

Malgaigne  only  aspirated  under  four  months  of  age, 
and  in  older  patients  when  life  was  threatened. 

Langenbeck,  1850,  operated  by  puncturing  the  cranial 
cavity  through  the  orbit,  entering  the  anterior  horn  of 
the  lateral  ventricle,  passing  the  trocar  under  the  lower 
lid. 

Geo.  C.  Blackman,  1854,  records  69  operations,  from 
which  the  following  deductions  are  made :  There  were 
24  males,  20  females,  and  in  15  cases  sex  was  not  stated  ; 
32  patients  were  under  1  year,  2  of  these  being  under  1 
month  ;  6  patients  were  from  1  to  2  years,  one  2  years 
old,  and  the  ages  of  17  were  not  given.  Sixteen  recov- 
ered, and  53  died.  Ages  in  patients  that  recovered  were  1 2 
years;  2, 4  months;  1,3 months;  and  1,  20 months.  The 
ages  of  8  are  not  given.  In  the  patients  that  recovered, 
congenital  enlargement  occurtd  in  1,  and  in  the  others 


from  a  few  clays  to  14  months  after  birth.     There  were  8 
females,  5  males,  and  in  3  sex  was  not  given. 

In  the  patient  12  years  old,  the  head  was  a  third 
larger  than  was  natural ;  6  pounds  of  fluid  was  drained 
away  in  20  days.  Patients  were  heard  from,  90  days  to 
8  years  afterward.     Health  and  intellect  were  good  in  all 


w 

^ 

^^ 

A 

^^"^""'••w^^H 

KU-^>i^^''\ 

r 

From  U.  S.  College  Veterinary  Surgeons,  Washington,  D.  C.    Sliull  of 
hydrocephalic  calf  two  days  old. 

of  them.     In  those  that  died,  death  occurred  from   1  to 
115  days  afterward. 

Autopsy  showed  dilation  of  the  ventricles,  atrophy 
of  the  pineal  gland,  and  very  little  trace  of  choroid 
plexuses.     The  cavity  of  the  brain  was  filled  with  clear 


water,  brain  was  atrophied  ;  dura  mater  thickened,  pia 
mater  inflamed. 

Gibson,  1857,  records  a  case  of  spina  bifida  with  post- 
natal hydrocephalus  in  which  paracentesis  capitis  was 
performed  17  times. 

Thompson,  1864,  cured  a  patient  with  hydrocephalus 
by  paracentesis  capitis. 

A  case  of  chronic  hydrocephalus  in  which  the  patient 
was  successfully  operated  upon,  is  reported  in  the  Glas- 
gow Medical  Journal,  1866-67,  i,  162. 

Kidd,  1866,  records  a  cure  following  paracentesis  for 
chronic  hydrocephalus. 

Palmer,  1884,  cured  a  patient  with  chronic  hydro- 
cephalus by  tapping. 

Morris,  1887,  speaks  of  a  case  of  hydrocephalus  in 
which  the  patient  responded  to  surgical  treatment. 

A.  D.  Stapleford,  Cincinnati,  February,  1904,  reports 
the  following : 

In  the  case  of  congenital  hydrocephalus,  1887,  I  performed 
paracentesis  of  the  cranium  by  the  use  of  a  small  trocar,  one- 
eighth  inch  in  diameter.  Selected  site  for  puncture  at  a  point 
one  and  a  half  inches  to  right  of  median  line  on  a  line  corres- 
ponding to  union  of  frontal  with  parietal  bone.  Withdrew  lour 
ounces  of  clear  straw-colored  fluid  at  first  sitting.  The  antici- 
pated collapse  did  not  occur.  There  were  no  difficulties  experi- 
enced. Four  ounces  was  removed  each  succeeding  day,  clos- 
ing the  opening  each  time  with  pad  of  iodoform  gauze  held 
firmly  in  place  with  strip  of  surgeons'  rubber  adhesive  plaster. 
At  times  1  felt  that  I  could  remove  any  quantity  with  impunity, 
and  would  often  allow  double  the  usual  quantity  to  drain 
away.  The  total  amount  removed,  (about  13  pints),  did  not  all 
exist  at  the  same  time,  as  the  cavity  was  observed  to  refill  dur- 
ing the  intervals  of  removal.  The  residual  fluid  which  I  was 
unable  to  withdraw  amounted  to  between  one  and  two  pints. 
The  enormous  growth  of  bone  on  the  left  side  was  not  discov- 
ered before  the  operation,  it  was  thin  and  had  not  interfered 
with  the  translucency  of  the  cranium.  Its  presence  made  it 
impossible  to  empty  the  cavity  completely,  and  would  have 
rendered  nil  any  good  effect  of  the  operation  had  the  child  con- 
tinued to  live. 

Ewart  and  Dickenson,  1891,  report  two  cases  of 
chronic  hydrocephalus  in  infants  in  which  treatment 
consisted  of  tapping  and  the  introduction  of  air  in  the 
place  of  the  fluid. 

Mauny,  1893,  trephined  and  drained  in  hydroceph- 
alus. 

Roswell  Park,  1893,  "operated  at  the  base  pos- 
teriorly, gouging  away  the  bone  one  inch  below  the 
superior  curved  line  of  the  occiput,  and  a  half  inch  to 
the  right  of  the  median  line,  incising  the  dura  mater, 
and  with  a  probe  opening  up  the  subarachnoid  space." 


Moseley,  1894,  aspirated  the  lateral  ventricles  for 
hydrocephalus. 

Glynn  and  Thomas,  1895,  record  a  case  in  which 
they  trephined  and  opened  the  fourth  ventricle  with 
recovery  of  the  patient. 

Bilhaut,  1895,  made  a  circular  craniectomy  to  drain 
in  hydrocephalus. 

Gordon,  1897,  mentions  the  treatment  in  a  case  of 
adult  hydrocephalus  by  supratentorial  and  subtentorial 
oi)eration. 

Good,  1897,  cured  by  operation  a  patient  with  hydro- 
cephalus and  .Jacksonian  epilepsy. 

Bruce  and  Stiles,  1897,  drained  through  the  fourth 
ventricle  in  a  case  of  acquired  hydrocephalus  due  to 
chronic  nontuberculous  basal  meningitis. 

Stewart,  1897,  reports  a  case  of  unilateral  hydro- 
cephalus, epileptiform  convulsions,  and  hemianopsia, 
treated  by  drainage  of  lateral  ventricle. 

Declen,  1898,  punctured  and  drained  the  lateral 
ventricle  in  hydrocephalus. 

Grosz,  1899;  Keen,  1899;  and  Dehler,  1899,  each 
resorted  to  ventricular  drainage  for  hydrocephalus. 

Davis,  1900,  made  a  craniotomy  and  drained  in  a  case 
of  hydrocephalus. 

Ricketts  reports  three  cases,  viz.,  (1)  rupture  of  lateral 
ventricle  ;  (2)  operation  ;  (3)  operation. 

Cumston '  reports  a  case  of  spina  bifida  in  a  child  of 
11  months.  Family  history  of  syphilis,  a  brother  or 
sister  of  the  child  had  hare-lip.  Fourth  and  fifth  tho- 
racic vertebras.  Operation,  cyst  connected  with  cord. 
Dissection,  sac  cut  away.  Death  on  fifth  day.  Anterior 
fontanel  became  tense.  Autopsy,  ventricles  distended 
with  fluid.  Internal  and  external  hydrocephalus  pres- 
ent. 

BIBLIOGRAPHY. 

Fabricius  Hildanus:  Observ.  Chirurg.  cent,  iii,  obs,  17. 

Odier,  H. :  Leipzig,  1785. 

Vose,  J.:  Med.-Chir.  Tr.  London,  1818,  ix,  354-358. 

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Hood  :  Ed.  Med.  and  Surg.  Jour.,  Vol.  xvii,  p.  516,  October,  1821. 

Delafield,  E. :  American  Medical  Recorder,  Philadelphia,  1821,  iv, 
448-453. 

Whitmore:  American  M.  Recorder,  July.  1821. 

Micheali.s,  Englischen  milgetheilt  J.  d.  Chir.  u.  Augenh.,  Berlin, 
1822, iv,  140-158. 

Fenoglio,  G.  C. :  Ann.  Univ.  di  Medical,  Milano,1823,  xxviii,  372-379. 

Rurrell :  Ed.  Med.  and  Surg.  Jour.,  Vol.  xxxvlil,  p.  43.  Graefe  and 
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Fourcade:  Lancette  Francaise,  Vol.  iv,  No.  47,  p.  188,  reports  from 
recollection,  case  operated  on  by  Dr.  Bidor. 


Marsh:  Medical  Gazette,  Vol.  xvii,  p  985. 
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Smith,  J.  R. :  London  Med.  Gaz.,  1839-40,  xxv,  83-94,  2,  pi. 

Dickinson,  J. :  Lancet,  London,  1839,  ii,  42. 

Tetlow:  Gaz.  d.  Hop,,  Paris,  1839,  i,  185. 

Kilgour,  A. :  Edinburgh  Med.  and  Surg.  Journal,  1840,  liii,  363-366. 

Malgaigne  :  Bull.  Gen.  de  Therap.,  Paris,  1840,  xix,  226-238. 

Watson:  In  Tweedies  Lib.  of  Medicine,  p.  147. 

Crooker:  Dublin  Med.  Press,  1840,  iv,  148. 

Clark,  H.  G. :  New  England  Q.  J.  M.  and  S.  Boston,  1842-3,  i,  420-3. 

Kilgour:  Ed.  Med.  and  Surg.,  Jour.,  Vol.  liii,  p.  365. 

Coldstream,  J.:  London  and  Edinburgh  Monthly  Journal  Medical 
Science,  1841,  i,  255-257. 

West,  C. :  London  Medical  Gazette,  1812,  xxx,  127-138. 

Glover:  Phila.  Jour,  of  Med.  and  Phys.  Sciences,  Vol.  ii,  p.  159. 

Durand-Faradel,  C.  L.  M. :  Bull.  Gen.  de  Therap.,  Paris,  1842,  xxiii, 
190-9 

Wutzer,  C.  W. :  Orig.  f.  d.  Ges.  Heilk.,  Bonn.,  1842-3,  ii,  113-6. 

Pancoast :  Med.  Exam.,  Philadelphia,  1843,  vi,  291. 

Chater:  Prov  Med.  and  Surg.  Jour,  1845. 

Edward,  J.:  Monthly  J.  M.Sc,  London  and  Edinburgh,  1846.  vi,  398. 

Heidenreich:  Leichenottnung  Med.,  cor-bl   bayer  aerzte,  Erlaug., 
1847,  viii,  441-445. 

Edwards,  P.  G. :  South.  J.  M.  and  Pharm.,  Charleston,  1847,  ii,  148- 
152. 

Fletcher:  London  Med.  Gaz.,  1847,  iv,  208. 

Parkraan  :  Amer.  Jour.  Med.  Sci..  October,  1848,  xvi,  299. 

Armstrong,  C. :  Dublin  q.  J.  M.  Sc  ,  1848,  vi,  215. 

Kitsell:  Prov.  Med.  and  S.  J.,  London,  1819,  431. 

Bellingham,  O.  B.  :  Dublin  Med.  Press,  1849,  xxii,  210. 

Taylor:  London  Med.  Gaz..  1850. 

Battersby,  F. :  Edinburgh  M.  and  S.  J.,  1850,  Ixxiv,  46-73. 

Pepper:  Q,uar.  Sum.  Trans,  of  Col.  Phys.  and  Surg.,  Phil.,  Vol.  iii. 

Alison,  J. :  Ed.  Med.  and  Surg.  Jour.,  Vol.  xliii,  p.  359. 

Collins,  G.  L. :  Boston  M.  and  S.  J.,  18.50,  xlii,  80. 

Howard,  M. :  Transylvania  M.  J.,  Louisville,  1851-2,  i,  37:3-377. 

Heidborn:  Woch.  f.  d.  Ges.  Heilk.,  Berlin,  1851,  xvii,  .536-551. 

Detmold  :  N.  Y.  Med.  Times,  185:3-4,  iii,  363. 

Blackman,  G.  C. :  New  York  Journal  of  Medicine,  1854,  xii,  219-349. 

Mussner:  Du  Kinderkrankheiten,  Vol  ii,  p.  187. 


Menschel :  Med.  Ztg.,  Berlin,  1855,  xxiv,  37. 

Lambert,  T.  T. :  Med.  Times  and  Gazette.  London,  1855.  xi,  222. 

Kunkler,  G.  A. :  West.  Lancet,  Cincinnati,  1856,  xvii,  267-269. 

Gibson,  J.  B. :  Med.  Chron.,  Montreal,  1867,  iv,  245-248. 

Cases,  Med.  Times  and  Gazette,  London,  1857,  xiv, 489. 

Wilks  and  Bryant :  Lancet,  London,  1S.")8,  ii,  654 

Chippendale,  W.  :  British  M.  J.,  London,  1858,  2,59. 

Hevfeldcr,  J.  F.:  Deutsche  Klinik.,  Berlin,  1858,  x,449. 

Kliuisciie,  J.  f.  Kinderkr.  Erlang.,  1858,  xxi,  212-223. 

Lawrence  :  Med.  Times  and  Gazette,  London,  1858,  xvi,  12. 

Lancet,  London,  1858,  i,  583. 

Hahn,  G.  A.  F. :  Berolini,  ia59. 

Marsh,  M. :  New  Orleans,  Med.  News  and  Hosp.  Gazette,  1860-61, 
vii,  13-16. 

Rogers:  Med.  Times  and  Gazette,  London,  1800,  ii,  613. 

Van  Gondoever,  I.  C. :  Nederl  Tijdsehr.  v.  Heel-en  Verlosk, 
Utrecht,  1862-3,  xiii,  240-249. 

Thompson,  T.  Y. :  Med.-Chir.  Tr.  London,  1864,  xlvii,  289-293. 

Clarecus,  F. :  Hygiea  Stockholm,  1864,  xxvi,  410-415. 

Kidd,  L.  A  :  Indian  Med.  Gazette,  Calcutta,  1866,  i,  184. 

Braeey,  C.  J. :  British  M.,  London,  1870,  ii,  6,i6. 

Nemmerl:  St.  Petersburg  Med.  Ztschr.,  1870,  i,  84-86. 

Buttenwieser :  Von  Bresgen  Deutsches  Arch.  f.  klin.,  Med.,  Leipzig, 
1872,  X,  301-304. 

Hecht,  A.:  Casop.  lek.  eesk.  v.  Praze,  1S73,  xii,  129. 

Busey,  S.  C. :  Tr.  Med.  .Soc,  Dist.  of  Columbia,  Washington,  1876,  iii, 
38-40. 

Moore,  N. :  St.  Bartholomew  Hospital  Report,  London,  1878,  xiv, 
161. 

BIBLIOGRAPHY. 

Puncture,  Cranial. 

Brinckhoff,  W. :  Griefswald,  1881. 

Dunn,  H.  P.  :  Lancet,  London,  1882,  i,  779. 

Palmer,  J.  G.  :  Med.  Record,  New  York,  1884,  xxvi,  705. 

Johnston,  W. :  Tr.  Mississippi  Med.  Assoc,  1885,  85-7. 

Stapleford,  A.  D. :  Cincinnati  Lancet-Clinic,  1887,  xix,  68. 

Morris,  R.  T. :  New  York  Med.  Jour.,  1887,  xiv,  319. 

Pfeiffer,  C.  F.  C. :  Griefswalder  Medizinischen  Klinik.,  Griefswald, 
1888 

karnitski,  A.  O. :  Protok.  Zasaid,  Obsh.,  Kievsk.,  Vrach.,  1888-9, 
pt.  2,  38-59. 

Pott,  R. :  Jahrb.  f.  Kinderh.,  Leipzig,  1890,  xxxi,  34-50. 

Ewart  and  Dickinson:  British  Med.  Jour.,  London,  1891,  ii,  602-605. 

Phocas,  G. :  Rev.  Mens.  d.  Mai.  de  I'enf.,  Paris,  1892,  x,  75-81. 

Piechaud  :  Assoc.  Franc,  de  Chir.  Proc-verb,  Paris,  1893,  vii,  697. 

Mauny :  Assoc.  Franc,  de  Chir.  Proc-verb.  Paris,  1893,  vii,  693-697. 

Park-Connor  and  Chornomer:  Keating  Cyclopedia  Diseases  of 
Children,  1899. 

Zadernovski,  F.  V. :  Vrach.  St.  Petersburg,  1893,  xiv,  884,  917,  976, 
1082. 

Boltze,  O. :  Halle,  A.  S.,  1893.    Miinch.  raed.  Woch.,  1893,  kl.  304. 

Hern,  J. :  British  Med.  Jour.,  1893,  ii,  1046. 

Lamphear,  E. :  Jour.  Amer.  Med.  Assoc,  1894,  xxii,  116. 

Nuijens,  F. :  Ann.  Society  de  Medical  d'Anvers,  1894,  Ivi,  147-163. 

Durand  :  Arch.  Prov.  de  Chir.,  Paris,  1894,  iii,  522-533. 

Zaleski,  K. :  Gaz.  Lek.  Warszawa,  1894,  xiv,  1347-9. 

Mosely,  G.  T. :  Tr.  Homeop.  Med.  Society,  New  York,  1894,  xxix, 
111-113. 

Raczynski,  J.:  Przegl.  Lek.  Krakow,  1894,  xxxiii,  469-484. 

BIBLIOGRAPHY. 
Puncture,  Cranial. 

Terrier,  F. :  Progres  Medicale,  Paris,  1895,  ii,  225-7. 
Glynn  and  Thomas  :  Lancet,  London.  1895,  ii.  1106. 
Power,  D.  A.:  International  Clinic,  Philadelphia,  1895,  5s.  iii,  251- 
262. 

Tribondeau,  L.  M.  F.  A. :  Bordeaux,  189.5. 
d'Astros,  L.:  Med.  Inf.,  Paris,  1895,  Ii,  60:i-609. 


9 

Bilhaut:  Assoc.  Franc,  de  Chir.,  rroc-verb..  1894,  Paris,  1895,  viii, 

^^^Aleksandroflf,  L.  P. :  Otchet  Dietsk  Boon,  Sv.  Olgiv.  v.  Mosk.,  (1895), 

^^^Vchimni  F. :  Miinch.  med.  Woch..  1898.  xliii,  8-10. 

Gordon.  W.:  Lancet,  Liondon,  1897,  1,91-96.  lon-r  •,-  i 

Good? J   W. :  Manitoba  and  W.  Canada  Lancet,  Winnipeg  1897  v,  1. 
Lemaistre,  J.:  Jour,  de  Clinic  Ct.  de  Therap.  Inf.,  Pans,  1897,  v, 

^^^tutherland  and  Cheyne,  A. :    Tr.    Clinic  Society,  London,  1897-S, 

^"""Bruc^eand  Stiles:  Tr.  Med.-Chir.  Society,  Edinburgh,  1897-5,  xvii, 

^^Stewart:  Scottish  Med.  and  Society  Jour.,  Edinburgh,  1897,1,805- 

^^^"Sutherland  and  Cheyne:  British  Med.  Jour.,  London,  1898,  ii,  1155- 

Schramm   H.:  Przegl.  lek.  Krakow.,  1898,  xxxvii,  451-464. 
Declen  K  A.  F  :  Mid.  Weekbl.,  Amsterdam,  1898-9,  v,  245-255. 
Schrarnm',  H. :  Klin-Therap.  Woch.,  1899,  vi,  97-102. 
Grosz  J  -Pest  Med.-Chir.  Pres-se,  Budapest,  1899,  xxxv,  48.5-487. 
Keen  W.'w!:  International  Clinic.  Philadelphia,  1899;  9s,  ii,  171. 
clhler  A. :  Festchr.  z.  Feier  v.  d.  Phys.,  Med.  Gesellsch.  zu  Wurz- 

^"'"u'avi's '  E."?.':  Arch.  Pediat.  New  York,  1900,  xvii,  .497-500. 

mmas  K:  Bull,  et  Mem.  Society  de  Chir.,  Par-.s,  1901,  xxvu,  828- 
830. 

Chapter  II. 

Lumbar  puncture  to  drain  hydrocephalic  fluid  has  not 
as  yet  resulted  in  a  cure.  In  a  few  cases,  slight  improve- 
ment and  considerable  comfort  have  ensued.  Repeated 
punctures  at  intervals  varying  in  length  have  been  prac- 
tised aseptically,  but  the  cerebral  fluid  cannot  be  removed 
by  a  lumbar  puncture  in  all  cases. 

However,  this  method  might  prove  successful  if  con- 
tinuous aseptic  drainage  could  be  maintained  from  the 
onset  of  the  disease. 

Quincke,  1891,  resorted  to  lumbar  puncture  for  the 
relief  and  cure  of  hydrocephalus. 

Koster,  1892,  succeeded  in  removing  the  cerebral 
fluid,  but  without  any  permanent  beneficial  results. 

Parkin,  1893,  made  basal  drainage  in  hydrocephalus. 

Raczynski,  1898,  resorted  to  lumbar  puncture  in  a  case 
of  hydrocephalus. 

Maisch,  1897,  made  repeated  lumbar  punctures  for 
therelief  of  hydrocephalus,  with  resulting  great  improve- 
ment and  comfort.  ,  ^^  .,. 

Bauermeister,  1898  ;  Pozzolo,  1901 ;  and  Varavssilis, 
1901,  each  resorted  to  lumbar  puncture  in  cases  of  hydro- 

*^^^Tyler  and  Williamson,  1903,  discovered  hydatid  cyst 
in  the  spinal  cfhial  by  aspiration. 

BIBLIOGRAPHY. 
L/umbar  ptmrture- 

Quincke,  H.:  Berlin,  klin.  Woch..  1«9^, ''^ viii,  929  9(!5. 
Koster,  H.:  Goteborg's  lak-sallsk.  Forh,,  189.',  122-129. 


10 

Parkin,  A  :  Lancet.  London.  189;J,  ii,  1244. 

Park,  K.:  Medical  News,  New  York,  1897.  Ixx,  432^35. 

Kacynski:  Conipt.  Rend.  Cong.  International  de  Medical,  1897, 
Moscow,  1898,  ill,  Section  6,  76-79. 

Maisch,  C.  O.:  Po.st-graduate,  New  York,  1897,  xii,619. 

Bauermeister,  W.:  Verhaudl.  d.  Versamml.  d.  Gesellsch.  f.  Klnderh. 
Deutsch.  Natiirf.  u.  Aerzte,  1897,  Wiesb.,  xiv,  224-230. 

Pozzolo,  G.:  Riv.  Veneta  di  Sc.  Med.,  V'enezia,  1901,  xxxiv,  .531-534. 

Caravassilis:  Ann.  de  Medical  et  Chir.,  Anf.,  Paris,  19ul. 

Caravassilis  :  AUg.  Wieu.  Medical  Ztg..  1901,  xlvi,  592. 

Tyler  and  Williamson  :  British  Medical  Journal,  February  7, 1903. 

Chapter  III. 

Subcutaneous  Drainage. — Feiss  suggested  subcutane- 
ou.s  draiuage,  and  it  was  practised  by  Tiirck,  1885  to  1890, 
but  without  avail. 

Seiin  ♦  attempted  to  drain  subcutaneously  in  a  case  of 
internal  hydrocephalus,  the  object  being  to  avoid  infec- 
tion. The  patient  died  somewhat  unaccountably.  No 
autopsy  was  permitted,  though  marked  improvement 
seemed  to  follow  the  operation. 

He  says,  "  the  case  indicated  that  subcutaneous 
drainage  is  preferable  to  open  draiuage,  and  proves  con- 
clusively that  the  cerebrospinal  fluid  is  quickly  absorbed 
by  the  connective-tissue  elements  as  soon  as  it  escapes 
from  the  ventricles." — {Journal  American  Medical  Asso- 
ciation.) 

Chapter  IV. 

Compression  of  the  cranium  for  hydrocephalus  has 
been  frequently  practised  with  more  or  less  benefit,  for 
almost  a  century. 

Ifuslin  bandages  have  been  firmly  adjusted  and  read- 
justed daily,  and  kept  moistened  with  water  to  contract 
them. 

Adhesive  planter  has  also  been  applied  after  the  scalp 
has  been  divested  of  its  hair.  Straps  of  this  material  do 
not  require  readjustment  as  often  as  muslin. 

Rubber  bandages  are  probably  the  most  desirable  for 
bandaging  the  head  in  treatment  of  hydrocephalus  as  the 
pressure  is  greater,  more  uniform  and  constant,  less 
olijectionable  than  plaster  and  can  remain  longer  than 
muslin  without  readjustment. 

Blanc,  1821,  mentioned  compression  as  a  most  effica- 
cious means  of  effecting  a  cure  in  certain  cases  of  hydro- 
cephalus. 

Girdlestone  and  Costerton,  1822,  employed  compres- 
sion with  most  satisfactory  results  in  certain  cases  of 
hydrocephalus. 

Barnard,  1825,  succe.ssfuUy  treated  a  patient  with 
chronic  hydrocephalus,  by  compression. 


11 

Compression  is  mentioned  in  the  London  Lancet, 
1838,  1839,  i,  376,  as  a  most  useful  method  in  dealing  with 
hydrocephalus. 

Trousseau,  1843,  resorted  to  compression  with  gratify- 
ing results  in  a  case  of  chronic  hydrocephalus. 

Baader,  1848,  employed  compression,  and  the  appli- 
cation of  turpentine  in  the  early  stages  of  chronic  hydro- 
cephalus, with  beneficial  results. 

Phillips,  1857,  resorted  to  elastic  pressure  in  a  case  of 
hydrocephalus. 

Didion,  1858,  combined  compression  with  dramage 
in  a  case  of  hydrocephalus  with  marked  improvement. 

Koux,  1859,  employed  this  treatment  in  a  case  of 
hydrocephalus,  benefiting  the  patient  materially. 

Lowenhardt,  1888,  compressed  in  hydrocephalus, 
greatly  lessening  the  size  of  the  head  for  a  considerable 
time. 

BIBLIOGRAPHY. 
Compression. 

Blanc  G.:  London  Medical  and  Physical  Journal,  1821,  xlvi,  353-356. 
GirdlestoneandCosterton:  Medical  and  PhysicalJournal,  London, 

"Barnard,  J.  F.;   London  Medical  Repository,  1S25,  i,  262.    Lancet, 
London,  1838-9,  1,376.  ..,.,.     ,0.0   •    ^,^-, 

Trousseau,  A.:  Journal  de  Medical,  Fans,  1843, 1, 107. 
Baader,  F.:  Journal  f.  Kinderkr.,  Berlin,  1848,  x,  413-422. 
Phillips,  R.:  Lancet,  London,  1887,  ii,  543-545.        ^,  ^     ^     ,     .,   „^„„ 
Didion,  J.:  Expo.se  d.  Trav.  de  la  Society  d.  fee.  Med.,  de  la  Moselle 

Metz.,  ia58, 396-404.  ^      .  „.  „     ■     ic=:..      ••    ^-<,  la^ 

Roux  flls :  Monit.  d.  Sc.  med.  et  Pharm.,  Pans,  1S59,  vii,  1/8-181. 
Lowenhardt :  Woch.  f.  d.  Ges.  Heilk.,  Berlin,  1888,  iv,  593-bOO. 

Chapter  V. 

The  seton  has  been  employed  for  many  years  in  the 
treatment  of  hydrocephalus.  It  is  especially  adapted  to 
the  arachnoid  type,  and  in  the  early  stage  of  the  disease. 

It  is  efficacious,  as  it  permits  of  constant  drainage 
indefinitely  or  until  the  desired  end  is  accomplished, 
whether  it  is  partial  or  complete  obliteration  of  the 
arachnoid  cavity  or  otherwise. 

The  seton  can  be  used  in  any  form  of  hydrocephalus, 
gauze  probably  being  the  most  desirable  material  to  be 
employed. 

It  should  be  passed  through  the  anterior  fontanel,  its 
exit  to  be  the  posterior  fontanel  on  each  side  of  the 
median  line,  and  it  should  be  reapplied  daily  with  aseptic 
precautions. 

Histori/. —Chsiter,  1845,  treated  a  patient  with  hydro- 
cephalus by  instituting  drainage  and  seton ;  death  fol- 
lowed. 

Grantham,  1854,  reported  a  case  of  hydrocephalus  in 


12 

which  he  made  repeated  punctures  and  employed  the 
seton. 

Demeaux,  1854,  drained  and  introduced  a  seton  in  a 
ease  of  hydrocephalus. 

Kennedy,  1867,  records  his  observations  on  hydro- 
cephalus, and  its  treatment  particularly  by  the  use  of 
setons. 

A  case  of  hydrocephalus  is  reported  in  the  Irish 
Hospital  Gazette,  1873,  i,  134,  in  which  cure  followed  the 
use  of  the  seton. 

Haven,  1882,  resorted  to  puncture  and  "antiseptic" 
drainage  in  hydrocephalus. 

BIBLIOGRAPHY. 

Seton. 

Chater.  G.:  Prov.  Medical  and  Society  Journal,  London,  1845,599-602. 

Grantham,  J.:  Medical  Times  and  Gazette,  London,  1854,  ix,  110. 

Demeaux  :  Monit.  d.  Hop.,  Paris,  1854,  ii,  li47. 

Kennedy,  H.:  Dublin  Q.  J.  M.  Sc,  1867,  xliii,  193-204.  Irish  Hosp. 
Gaz.,  Dublin,  1873,  i,  134. 

Haven,  H.  C.:  Boston  Medical  and  Surgical  Journal,  1882,  cvi,  266. 

Chapter  VI. 

Cranial  injection  is  one  of  the  most  dangerous,  irra- 
tional, and  ineffectual  of  all  the  methods  employed  for 
the  cure  of  hydrocephalus. 

Various  kinds  of  astringents  and  irritating  solutions 
have  been  used  with  but  little  if  any  good  effect.  They 
have  been  injected  into  the  cyst  both  before  and  after 
the  removal  of  its  contents.  Some  operators  have 
increased  the  strength  of  the  medicament,  at  the  same 
time  removing  more  or  less  of  the  contents  at  intervals 
of  days,  weeks,  or  even  months. 

Injection  of  lodin. — Boinet,  1856,  after  removing  the 
fluid  in  a  case  of  congenital  hydrocephalus,  injected 
tincture  of  iodin. 

Hayden  resorted  to  the  same  treatment  during  this 
year. 

Brainard,  1859,  made  multiple  injections  of  tincture 
of  iodin  into  a  hydrocephalic  tumor. 

Racis,  1865,  made  repeated  injections  of  iodin  in  a 
case  of  chronic  hydrocephalus. 

Lauder,  1881,  employed  iodin  injections  in  cases  of 
hydrocephalus. 

BIBLIOGRAPHY. 
Injection,  Iodin. 

Boinet ;  Bull.  Soc.  de  Chir.,  Paris,  1^56-7,  vii.  386-392. 

Hayden,  T.:  Dublin  Hosp.  Gazette,  1856,  iii,  168. 

Brainard,  D.:  Chicago  Medical  Journal,  1859,  xvi,  198-216. 

Racis  :  Proc.  Verb  Society  de  Medical  de  Strasbourg,  1865-6,  iii,  61-70 

Lauder,  R.:  New  England  Medical  Monthly,  1881-2,  i,  9. 


13 


Chapter  VII. 
Internal    Treatment. — Greatwood^    claimed    to   have 
efff(  ted  a  cure  in  a  case  of  hydrocephalus  by  the  internal 
adniinistration  of  potassium  hydriodate. 

Chapter  VIII. 
Topical  Treatment. — Hannay,*  1843,   applied  a  lini- 


6,410,  U.  S.  Museum.— Skeleton  of  a  dwarf  (Thippewa  Indian  squaw, 
aged  85.  The  brain  of  this  subject  constitutes  specimen  "  1,031  b" 
of  the  Anatomical  Section.  The  dura  mater  and  scalp  constitute 
specimen  "  1,031  C"  of  the  Anatomical  Section. 

ment  combined  with  ipecacuanha  to  the  scalp  in  hydro- 
cephalic cases. 

Electricity. — Brenner    and     Januszkjewitsch,     1H70, 
employed  galvanopuncture  in  a  case  of  hydrocephalus. 

BIBLIOOR.\PHY. 

Brenner  and  Januszkjewitsch;  St.  Petersburg  Medical Ztschr.,  ISTO, 
1,25-31. 


14 


CONCLUSIONS. 


Hydrocephalus  and  spina  bifida,  7  months. 
(From  personal  collection.) 


1.  Excessive  se- 
cretion of  the  cere- 
l)ial  meninges  may 
occur  in  any  form  of 
animal  life. 

2.  The  various 
forms  of  vegetable 
life  are  subject  to 
excessive  local  or 
general  secretion  to 
a  fatal  degree. 

3.  Hydroceph- 
alus, ventricular  or 
meningeal,  may  de- 
velop in  utero  or  at 
any  time  through- 
out infant  or  adult 
life. 

4.  The  cases  of 
spontaneous  recov- 
ery are  probably 
numerous,  espe- 
cially in  infant  life, 
in  which  the  arach- 
noid is  alone  in- 
volved. 

5.  All  cavities 
may  unite,  with  or 
without  external 
rupture ;  when  so, 
it  is  usually  fatal, 
not  necessarily  in- 
stantly so. 

6.  Spontaneous 
ruj)ture  may  occur 
externally  or  sub- 
cutaneously,  w  i  t  h 
an  occasional  recov- 
ery. 

7.  The  effusion 
may  be  into  the  lat- 
eral third  or  fifth 
ventricle,  or  it  may 
be  in  the  arachnoid 
or  subarachnoid 
cavity,  one  or  all. 


15 

8.  A  clot  in  the  arachnoid  cavity  may  cause  a  cyst 
which  will  enlarge,  with  all  its  consequences. 

9.  Syphilis,  tuberculosis,  and  rickets  have  been 
assigned  as  causes  of  hydrocephalus,  but  such  have  never 
been  proved  ;  the  cause  is  yet  unknown. 

10.  Sometimes  zones  of  new  osseous  material  are  scat- 
tered here  and  there  in  the  meninges,  and  sometimes 
upon  or  in  the  brain  substance. 

11.  The  septum  lucidum  is  invariably  thickened,  as 
are  the  cerebral  meninges  in  general. 

12.  Probably  the  greater  number  of  cases  of  early 
hydrocephalus,  whether  of  the  third,  fourth,  fifth,  or 
lateral  ventricle,  or  of  the  arachnoid  variety,  can  be 
cured  by  some  form  of  drainage. 

13.  Continuous  drainage  by  seton  or  the  repeated  use 
of  the  trocar  has  given  the  best  results  in  the  way  of 
benefit  or  cure. 

14.  Spinal  drainage  has  been  practised  in  a  very 
limited  degree,  and  its  value  is  as  yet  undetermined. 

15.  Subcutaneous  drainage  has  not  resulted  in  a  cure, 
but  there  seem  to  be  many  possibilities  for  this  method. 

16.  Trephining  for  drainage  is  only  resorted  to  in 
cases  in  which  the  fontanels  have  been  closed  by  bony 
union. 

17.  Results  from  drainage  are  more  favorable  if  done 
when  the  presence  of  fluid  is  first  detected. 

18.  It  is  sometimes  necessary  to  drain  both  hemi- 
spheres, together  with  the  right  and  left  cerebellar 
cavity. 

19.  The  secret  of  curing  arachnoid  hydrocephalus  by 
drainage  probably  lies  in  obliterating  the  arachnoid 
cavity.  However,  this  can  be  done  with  hydrocephalus 
of  the  third,  fourth,  and  fifth  ventricular  variety. 

20.  The  cardinal  principle  in  this,  as  in  all  operations 
upon  the  brain,  is  asepsis. 

Chapter  IX. 

Pathology. — The  word  hydrocephalus  should  be 
applied  to  noninflammatory  cerebral  exudation.  It  is 
found  alike  in  both  animals  and  man  and  is  due  to  the 
same  causes,  although  they  are  not  definitely  understood. 

Breschet  gives  five  varieties:  (1)  Between  dura 
raater  and  brain ;  (2)  between  dura  and  parietal  arach- 
noid ;  (3)  in  cavity  of  arachnoid ;  (4)  ventricles  (most 
common) ;  (5)  between  arachnoid  and  brain. 

It  is  thought  that  the  children  of  cretinous  parents, 
and  those  suffering  from  myxedema,  are  especially  sub- 


16 

jeet  to   hydrocephalus.     No    explanation  being  given, 
Dickenson  believes  rickets  to  be  a  cause. 

Syphilis,  both  hereditary  and  ac(iuired,  has  been 
accredited  as  being  a  cause,  while  tuberculosis  has  been 
more  frequently  so.  Embolisms  and  neoplasms  varying 
in  type  have  no  doubt  been  properly  classed  as  exciting 
causes. 

Arachnoid  engorgement  from  any  cause,  such  as 
rheumatism,  gout,  and  the  infectious  diseases,  are  sup- 
posed to  l>e  a  causative  factor. 

Rokitansky '  believed  the  seat  of  hydrocephalus  to  be 
in  the  lateral  ventricles,  while  Rilliet  and  Barthez* 
thought  that  hemorrhage  from  the  arachnoid  membrane 
is  the  cause  of  fluid  in  the  arachnoid  cavity,  for  in  this 
variety  the  fluid  generally  contains  blood. 

The  disease  may  originate  in  the  third,  fourth  or 
lateral  ventricles,  or  anywhere  in  the  arachnoid  cavity. 
It,  however,  is  supposed  to  occur  rarely  in  the  arachnoid 
sac. 

A  blood  clot  in  this  sac  may  cause  excessive  and 
serous  eff"usion. 

The  development  of  the  disease  may  be  unilateral  or 
bilateral,  and  remain  so,  or  when  in  one  ventricle  it 
may  rupture  into  the  other  or  into  the  arachnoid  cavity, 
one  or  both,  aud  thus  become  general  in  character. 

Nelaton  thought  that  spontaneous  recovery  would 
result  from  diarrhea,  copious  perspiration  and  cutaneous 
eruptions. 

HubbelP  reports  a  recovery  following  cutaneous 
eruption  upon  the  head. 

In  either  event  there  may  be  spontaneous  rupture 
externally  with  or  without  recovery.  If  rupture  does 
not  occur  externally  and  the  fluid  is  not  removed 
artificially,  hypertrophy  or  atrophy  of  the  brain  may 
ensue,  with  all  its  consequences. 

Zones  of  new  osseous  material  are  now  and  then 
found  scattered  here  and  there  in  the  meninges,  and 
sometimes  upon  or  in  the  brain  substance. 

It  is  not  known  whether  or  not  they  are  a  cause  or  a 
consequence  of  the  disease. 

The  cranial  bones  separate  in  the  young  before  union 
of  the  sutures  as  they  never  separate  after  that  time, 
consequently  hydrocephalus  is  confined  to  infancy.  The 
disease  may  not  manifest  itself  until  a  time  when  the 
sutures  should  be  united,  but  the  formation  of  the  fluid 
begins  before  the  sutures  unite,  and  is  the  means  of 
preventing  their  union. 


17 

Blackman  says  :  "  In  the  majority  of  cases  the  fluid 
is  confined  to'  the  ventricles ;   rarely  in  the  arachnoid 

However,  this  statement  is  very  much  questioned  a^ 
there  seems  to  be  no  special  age  for  hydrocephalus. 

J.  Lewis  Smith  thinks  congenital  hydrocephalus 
is  due  to  syphilis  alone. 

Spina  bifida  is  sometimes  associated  with  hydro- 
cephalus. , ,  , 

Destruction  of  bloodvessels,  laceration  or  pressure  has 
in  a  few  instances  resulted  in  gangrene  of  the  brain  sub- 
stance, and  in  certain  other  cases  of  continued  severe 
pressure  the  septum  lucidum  has  been  found  very  much 

Retzius,  of  Stockholm,  has  a  collection  of  large  hydro- 
cephali. 

BIBLIOGRAPHY. 

Skene,  C:  Deapoplexia  bydrocephalica,  Edinlnirgh  1799. 
Armstrong,  A.:  De  apoplexia  bydrocephalica,  Edinbu  gh.  1800. 
Moffat,  T. rbe  apoplexia  bydrocephalica,  Edinburgh,  1800. 
Weaver,  P.:  Another  case.  Med.  and  Phys.  Journal,  London,  1806, 

'''' Cllrke,  J.:  Case  of  apoplexia  hydrocephalica,  Edinburgh  M.  and  S. 
"'■'  ^M^'uto?E.:  A  case  of  cerebral  hemorrhage  in  hydrocephalus,  Paris, 
^^%isa-  Reports  a  apoplexia  serosa,  in  Bernt  J.  Gutachten  Wien., 
^«^R^h[Sncief'j."R.:U's\vfali^^^^ 

^^"so\oT^?VpSle''xirsir4ife'irky'^Jcephalus,  Journal  Univ.  et 

Hebd.deMed.Chir.  Prat.,  Paris,  1831,  iv,353-3tia  de  Med    et 

Harrotte:  Apoplexia  sereuse,  Journal  Univ.  et  Hebd.  de  mea.  ei 

''%£lys:Frcdsfo\'IhSi'Sa  hydrocephalus.  Lancet,  London,  18.50, 

'■^Lente,  F.  D.:  Casesof  serous  apoplexy.  New  York  Journal  Medicine, 

^^^^slnkey,  A.  H.:  Serous  apoplexy,  Med.  Times  and  Gazette,  London, 

^^^Merto^'s,  J.:   Observations  d.  apoplexie  sereuse,  Ann.  Soc.  Med. 

''''^:YrTeVfl::''on  the'ireatment  of  apoplexia  hydrocephalus,  Ann. 

Med   Psych.',  Paris,  1854,  vi,  197-220.  r.„,.;„     iocq 

Gourdon,  J.:    Apoplexia  hydrocephalus,  Gaz.  Hop.,  Pans,    1859. 

''''''pigulira,  M.:  Serous  apoplexy,  Gaz.  Med.  de  i^^^b  =  1862  33  61 

Kempter,  W.:  Serous  apoplexy,  Am.  J.  Insan.,  Ulica,  N.  \  ,  1868-9, 

'"'"'"I'sh^m  A.  B.:  Reports  sudden  death  in  general  effusion  of  serum 
into  encephalic  cavities,  enormous  enlargement  and  hypertrophy  of 
heart.  Clinic,  Cincinnati,  1873,  V,  206. 

Mathieu,   A.:   Serous  apoplexy,  France  Med.,  Pans,  1821,  i.  6J,- 

"'^^^  Wigglesworth,  J.:  A  case  of  serous  apoplexy.  Journal  Ment.  Sc  , 
London,  1884-5,  XXX,  551-553.  Mr,rtViiitrih 

Philipsen,  G.  H.:  Notes  on  serous  apoplexy.  Rep.  Prop.  Noithumu. 
and  Durham  M.  Soc,  Newcastle-upou-Tyne,  188.5-<),  L0-17J. 

Black  J  Q:  Notes  on  cerebral  serous  apoplexy  in  gouty  constitu- 
tion, Prov.  M.  J.,  Leicester,  1892,  xi,  398-401. 


18 

REFERENCES. 

1  Operations  de  Chirurgie,  third  edition,  1736. 

"Edinburgh  Medical  and  Surgical  Journal,  July,  1850. 

'^  Amei-icayi  Medicine,  July  25,  1903,  p.  158. 

^Senn,  Alienist  and  Neurologist,  .St.  Louis,  August,  1903. 

6  Am.  Journal  Medical  Science,  Philadelphia,  1851,  xxi,  1U9. 

'Edinburgh  Medical  and  Surgical  Journal,  1843,  Ix,  321. 

'Path.  Anatomy,  Syd.  Ed.,  Vol.  iii,  p.  366. 

*  Traits  des  Maladies  des  Enfants 

«New  York  Journal  of  Medicine,  ia50,  p.  396. 


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Surgery  of  the  prostate,  pan- 
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historical  review 


ZWO  100 
R539S 
190U 
Ricketts,  Benjamin  M 

Surgery  of  the  prostate,  pancreas, 
diaphragm,  spleen,  thyroid,  and 
hydrocephalus;  a  historical  review 


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